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·COLOR ATLAS AND MANAGEMENT Or VASCULAR DISEASE ·COLOR ATLAS and MANAGEMENT of

·WILLIAM T FOLLY MD TACT
Associate Professor of Clinical Vedicine Cornell University
Vledical College Associate Attending Physician and Chief of
the Vascular Clinic The len Jork Hospital
IRVING S WRIGJIT, MD JACP
Professor of Chucal Viedicine Cornell Unn ersity Niodical
College Attending Physician Thic Acu York Ilospital
VASCULAR DISEASE
APPLETON CENTUX1 Crofts, Inc
MEN JORK

·Copyright © 1959 by
APPLCTON CENTURY CROFTS INC
All rights rescried This book or parts
thereof must not bc reproduced in any
form thithout permission of the publisher
Librin of Congress Cud Number 59 9706
PRIVTED IY TIIE UNITED STATES OF AMERICA

·PREFACE Vascular diseases first recened serious clinical attention in this country about 30 years ago In the ensuing period there have been greit adı ances in diagnosis and therapy These have been subjected by the nuthors to constant testing m their hospital services and practices The authors huse also worked with the American Vledical Association the American Heart Association and the love York Heart Association to establish antions de criteria for nomenclature libora tory findings and clinical applications pertinent to the problems of circulator disease There has been a great deal of literature on the subject but there has been no book of color description Such a book will be most helpful to the practicing physician who has to deal with problems of dngnosis The color changes which must be understood for accurate diagnosis cannot be portrayed bx black and white illustrations The Color Atlas and Management of Vascular Discasc supplies this need From files including thousands of case histories carefully selected cases are discussed and the diagnosis and pathogenesis of the diseases are explained with their treatment The principles of theraps are on the whole conservative but some cases are described in which radıcıl measures were effec tre The details of surgical technic are not included because they are beyond the scope of this Atlas \evertheless surgeons will be greath interested in the conditions Illustrated The pictures presented in this Color Atlas were chosen from a collection of 600 photographs illustrating 200 cises started in 1946 These 192 color photographs illustrate the lesions of 94 patients which were taken by us or by Edgar | \chel of the Clas Adams Company These are also reproduced in transpirena form by the Clay Adams Company and duplicate slides mas be obtained from them for educational purposes or for illustrated lectures Nomenclature and Criteria for Diagnosis of the Discases of the Heart ani! Blood vessels published by the lew York Heart Association in 1933 his heen used as the basis for terminology We should like to thank Dr Harold Pardlec chairman of the parent committee for his permission to drau liberalls from the chapter on peripheral vascular disease in writing this Atlas We should also thank our associates on the subcommittee Ds Nelson W Barker Dr Paul J Klemperer Dr Joseph E Flynn Dr Gerald H Pratt and Dr llallace later who helped prepare thus section of the nomenclature and criteria Vliss Esther Judkins and Vliss Daphne Vorse of the library of The Rockefeller ·Vi Preface Institute and Miss Ann F Burke of the library of the Cornell University Medical College, have helped with the preparation of the bibliography The staff of the Vascular Clinic at Cornell including Dr Cllen McDevitt Dr Robert Huebner, Dr Francis Perrone Dr Jerrold Lieberman Dr Clur Gross Dr Irwin Werner Dr Walter Pulmer, and Dr Leonyrd Schuyler huve partici pated in the core of these patients The final manuscript was typed by Mrs Burbırı W Gatje of our rescarch staff Earlier versions were edited typed ind proofrend by Viss Gertrude C Smith and Miss Gertrude Rogers of The Rockefeller Institute Miss Gerd Stokke and Miss Irene R Moullin assisted with the galleys We thank each of them for their enthusiastic and expert help The cost of color printing is so grent that it would not have been possible to publish this book without the ud of Dr and Mrs Samuel Mulbink Gener il John Morgan Mrs Frank Corbett Mr Thornton Oxn ird Mr Jean Lambert Drs Eugene Daly and Piul MacLeod of the Eaton Laboratories and the late Mr Isaac Harter who have contributed toward the cost of production WILLIAU T FOLEY IRVING S WRIGHT ·CONTCNTS 1 PREFACE IT LIST OF CASES AVD ILLUSTRATIOS 1 I 5 6 I ARTERIAL DISEASES Acute Artonal Occlusion Chronic Arterual Insufficiency Summary Atherosclerosis Obliterans Arterosclerosis Monchebergs Vedul Type Thromboangutus Obliterans (Buergers Discase) Arterial Embolization IS 20 27 ro 2 VENOUS DISEASES I enous Insufficiency Thrombophlebitis Pulmonary Embolism and Infarction 29 36 65 3 LY VPHEDENIA Treatment and Classification Clinical Features Medical Management 65 66 69 85 4 VASOSPASVI AND DISEASES I\WHICH IT PLAIS AVAJOR ROLE Primary Raynauds Disease Acrocyanosis Liedo Reticulans Frostbite Pernio Chiblarns - Scleroderma Thromboangutis Obliterans Atherosclerosis Obliterans eurovascular Syndromes of the Shoulder Girdle Thrombophlebitis Phlebites with Gangrene Secondary to asospasm Peripheral Neuritis Ergot Poisoning Cryoglobulinemua Causalgia Sudeks Atrophy Tiheumatoid Arthritis and Collagen Diseases Periarteritis Modas Summary 86 89 90 92 96 101 105 105 110 110 119 114 116 118 121 122 123 vu

·Vu
Contents
5 AVEURISVI
125
Arteriovenous Anastomosis (Fistula)
126
111
6 DISEASES OF THE SMALL VESSELS
Increased Fragility of lessels
Increased Perineability of Vessels
Hypertensie Ischemic Ulcers
1442
143
119
7 BLOOD VESSEL TUMORS
151
Hemangioma
Hemangioendothelioma
Sarcoma
151
151
152
INDEX
169

·LIST OF CASCS AND ILLUSTRATIONS ARTERIAL DISEASES h 11 12 13 25 Case 1 Intermittent (laudication due to Atherosclerosis Obliterans Case ? Atherosclerosis Obliterans Duabetes Mellitus Slipertension (170/100) Gungrene of Left Foot Case 3 Atherosclerosis Obliterans with Occlusion of Bifurcation of Aorta Case 4 Calcification of Abdominal aorta with Complete Obstruction (ase 5 Atherosclerosis Obliterans with Cangrenous Ulcer Alcaled by Conservative Therapy Case 6 Atherosclerosis Obliterans Diabetes Mellitus #th Gingrene of Large Toc and Foot Cae 7 Atherosclerosis Obliterans Diabetes Mellitus with Cangrenc of Large Toe Case 8 Arteriosclerosis (Monchebergs Vledial Typel with extensive Calcification without Obstruction Case 9 Thromboangntis Obliterans Gingrene of Large Toe uith Ilcaling Case 10 Thromboangitis Obliterans Case 11 Thromboangutis Obhterans of Both Lower Extremities Case 12 Thrombounguitis Obliterans Quadrlateral Case 13 Thromboangutis Obliterans in a Woman Case 14 Embolus to Lower Extremities 10 17 JS 19 20 21 22 23 20 2 29 FNOUS DISFASES Case 15 Varicos Vens Ca e 16 Varicose Veins Stasis Dermatitis Ulceration Case 17 Chronic Venous Insufficiency Vanese lens Ulceration Case 18 Chronic lenous Insufficjency Varicose leins Ulceratron Case 19 Acute Superficial Thrombophlebitis in Varicose Seins sich Extension ta 32 33 31 35 Deep Veins 40 11 Case 200 (ronic Rt current Los Grade Phlebitis Case 23 Recurrent Idiopathic Phlebstis (Long Term Anticoagulant Therapy) Case 2 (ure inoma of Breast with Vultiple Jascular Thrombu Case 23 Pulmonary Embols Caying Right Heart Failure (ase 24 \fultiple Small Pulmonary Emboli Cise ?> fcute Pulmonary infarction 50 52 53 51 55 LX ·X List of Cases and Illustrations Cise 26 Pulmonary Emboli 56 57 Case 27 Pulmonary Embolus 58 Case 28 Pulmonary Embolism following Pelvic Thrombophlebitis 5S 59 Chse 29 Pulmonary Embolus Angiocardiogram 60 61 Case 30 Pulmonary Embolism Migritory Phlebitis Carcinomı of Pincruis 62 LIMPHEDEMA 70 71 72 73 74 75 76 Case 31 Aussie Lymphedeme of the Arm Cuse 32 Lymphedema of the Arm Case 33 Lymphedemn of the Arm Case 34 Lymphedemı of the Arm Case 35 Lymphedemi Praecox Case 36 Lymphedemı Praecox Case 37 Lymphedema Pruccor Case 38 Missie Lymphedema Pruccor Case 39 Lymphedema of Leg Secondary to Surgery in Groin Cuse 40 Lymphedemı of Hund Cases 41 42 and 43 Stasis Ulcerations and Edem 77 78 79 80 81 82 83 87 89 90 91 92 93 91 95 VASOSPASM AND DISEASES IN WHICH IT PLAYS A MAJOR ROLE Cuse 44 Raynauds Disease Case 45 Acrocyanosis Case 46 Luxedo Reticularis Case 47 Livedo Reticularis Case 48 Frostbite (Chilluns Pernio) Case 49 Frostbite with Ulccration Case 50 Frostbite Case 51 Trostbite associated with Neurovascular Syndrome of the Shoulder Gardie Case 52 Advanced Sclerodermi Case 53 Advanced Sclerodermi Case 54 Early Scleroderma Case 55 Advanced Sclerodermi in a Vinn Case 56 Tar Advinced Scleroderma sith Pulmonary Changes Case 57 Early Sclerodermi Case 58 Thrombongntis Obliterins Case 59 Hyperubduction Syndrome Case 60 Axillary Vein Thrombosis Case 61 Phlebitis (with Gangrene Secondary to Vasospasm) Case 62 Gangrene of the Tocs Secondary to Phlebitis with Visospasm 97 98 99 100 101 102 103 101 100 107 108 109 111 112 ·113 111 115 115 List of Cases and illustrations Case 63 Rrynauds Syndrome with Cangrene Secondan to Arsenical Vietlication Case 64 Acute Ergot Povoning with Cingrene of the Toes Case 65 Ergotamune Poisoning Cuse 66 Cryoglobulinemia Crse 67 Sudeks Atrophy (Traumatic Refier Tasospaste Distrophy with Osteoporosis following Fracture and Aullan Vein Thrombosis) Case 68 Persistent asospastic Phenomena following Trauma Case 69 Renaud, Syndrome Secondin to Rheumatoid Anintis Case 70 Perirrteritis Modosi 116 117 119 120 121 122 ANEURISME Case 7 Abdominal Aortic Aneurysm Case 72 Di secting Aneurysm of the Ports Case 73 Aneurysm of Innominate Artery Ca e 74 Arteriovenous Aneurysm Congenital Case 75 Arteroii nous Anastomosis Congenital Case "6 Arteriovenous Aneurysm Traumatic 129 129 130 331 132 133 131 135 130 137 135 139 DISEASES OF THE SMALL VESSELS Case Purpura with Agranulocytosis Case 78 Senile Purpura Case 79 Subclinical Scurry Case 60 Ciumcıl Scurvy Case 81 Hypertensive Ischemic Ulcers 146 118 1.19 BLOOD VESSEL TUMORS Case 82 Kaposis Sarcoma (Multiple Hemorrhagie Hemangioma of Aaposi) Case 83 kaposis Sarcoma Case 81 Laposis Sarcoma in a Viddle Aged Vlom in Case & Angiosarcoma Case 86 Casemous Hemangioma Case 87 Cavernous Hemangioma Case 89 Cavenous Vicmangioma Case 89 Cavemous Hemangioma Case 30 Capillary Hemangoma Case 91 Capillary Lymphangioma Ca e 92 Pulsating Angioma Case 93 Hemitocele Case 94 Pulsating Angioma 154 155 150 137 158 159 160 101 162 163 101 165 IGC 167

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·COLOR ATLAS AND MANAGEVIENT OF
VASCULAR DISEASE
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·ܢܙ Aiterial Diseases ACUTE ARTERIAL OCCLUSION Arterial occlu ion may be caused many decreasing pressure gradient and also in pathologic states However the most common many cases centralls Blood flow through the causes are thrombosis over the site of an spustic collateral sesscls becomes ven slug atherosclerotic plaque embolization from a gish There is a tendenc for slug_sh blood to fibrillating or infarcted heart and thrombosis clot in both artches and reins and in the associated with the inflammation of thrombo capillary beds (thrombosis in situ) angutis obliterans Adaptue Vechanisms To counterbalance Diagnostic Signs The diagnostic signs of the arterial occlusion and sasosp ism of col acute arterial occlusion in a limb are pallor an laterals sescral compensates, meclisms elevation cyanosis at 1 horizontal or dependent arc duscloped Von Recklinghausen (3) in level in the early stages coolness of the affected 1883 pointed out that the blood pressure rose area absent or greatly diminished peripheral above an arca of arterial blockage and fell arterial pulses and subnormal oscillometric below this site This produces a pressure readings Pain and numbness are usually pres gradient wluch promotes the deselor noast and ent The oscillometric readings are of salue in clficiency of collateral flow indicating the level at which the obstruction Brer (4) in 1897 demonstrated that in occurs Pulses which are occluded or dimin an area sith reduced arterial blood flow ished by vasospasm may be released from this catabolic products accumulate These products spasm and restored by sublingual mitroghc have a profound vasodilator or listamine lile crin given as a diagnostic test (1) action They tend to oi crcome the vasocon Physiologic Changes (Diagram 1) Fol stnctor action of serotonin and result in a lowing the formation of the clot or the lodge ment of the embolus a powerful vasocon marked dilatation of collateral vessels strictor agent appears to be hberated from the Thoma (5) in 1884 showed that the thrombus This has been named serotonin" by growth of collateral channels as proportional Rapport Green and Page (2) It produces a to the blood flow through them Lixis (6) spasm of the affected vessel and the adjacent in 1910 in a review of all the experimental collaterals This spasm may extend distally for data concerning collateral low concluded that many centimeters but may relax over a period "the essence of the matter seems to be that of hours or days after the first impact The thrombus has a tendency to propa there is a local call by tissues in need and that to this call there i5 7 local and adequate gate itself distally in the durection of the response" 1

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·3 Acute Arterial Occlusion agent in thromboingitis obliterans there is and extending to include the 11:10 arteries and cvidence to shon that the inflamation which segments of the fumoral arteries hase becn is the chur icteristic pithout me feature of the successfully useel They find their greatest value in the resection of aneurysms atlice to dise ise mus lx «lu to z peculiar KIOSITICT IS) sclerotic occlusion is with the Lerche syn to tohoco Thic inflammation is madly in drome and vessels infiltrated with timor gratited by the use of tob1een The ves el above and below and especially (b) WARUTI Heat should never be ip at the site of attachment of the grilt must le plied to an area with decreased into na fou healthy and patent for this procedure to be Hou esce when the per proximal tr> » » Successful It has been limited by the diffi Warmid Tefler vasodilatation su folio culty in obtaining suitable hornografts Ihe For crimple of the poplite il ten is exc development of plastic materials may over cluded a heating pad may loc placed on the come this problem abdomen or groin with benefit 2 The Use of Gravity To ad the flow (c) DRUGS of blood into collateral channels the affected (1) Systemic Tic use of general visa limb should be kept below heart lese! This dilators such as alcohal nicotinic acid der mav be accomplished by elevating the head tres herimethonium compounds priscoline of the bed on sıx to eight inch blochs The recitinc dibenzolme time that unmonum common error of raising the invoked limb on halid, ildir arlidin etc in the disud a pillow is to be deplored Alternately filling vantage of lilating the minute vascular bed the lumb with blood by making it dependent in nonnul areas as well as in the affected in and then draimng it by elevatin, it shghth where this effect is desircel Tlie net roule can be conveniently accomplished by the oscil max bc to decre ise blood low to the limb lating hud of which several types are av! * here it is most neeckd but where spism able The bed must be reçulated to suit each due to pain makes the vessels most resistant case The aim should be to obtain just enough to dilatation Some of these ngents also open elevation on the upswing to drain the seins but not to maintain it long enough to produce up the numerous Arterial enous slunts in the limb and dusert blood flow from the penplierul marked pallor The downswing should give tissues such as those of the toes or fingers to ample gravity pressure fiou to produre rubor if possible without reaching an angle uncom this by pass system further reducing Nou Cartable to the patient where it is required in our hands sylılın cal 3 Vasodilation Collateral vessels are very glyceryl trinitrate in 1 dose of 00001 gm kis Liven the maximum degree of dilatation of ensitive to environmental changes both lemical and physical Slight chilling <333 large ind small arteries for penals of one to ho hours it clocs not however act the ause extreme vasoconstriction Proper warmth musculture of the arteriolcs 'Therefore ay uces dilation of the arterial tree cept in cases of occlusion by spiss of the (1) AVOIDA\CE OF TOBACCO The use of obacco in any form produces profound vaso mayor ancres one should not expect an eles onstriction Some patients are much more fion of the temperature of the skin hs this drug Prusztive to this than others in these esen a ingle puff of 3 clasette may exuse measur (2) intraarterial Repeated injections into able isospasm Complete abstinence from an artery traumatize it This is more serious obacco us i sine qua non for successful thes when an irritating substance is injected and there is some local infiltration of the wall of 1p) In addition to acting as a sasoconstricting the vessel and surrounding tissurs Reiks ·2 Arterial Diseases 1 SCHEMATIC VIEW OF ARTERY IN LIMB WITH COLLATERALS 2 ACUTE ARTERIAL OCCLUSION CLOT FOAMS OR EMBOLUS LANOS PRODUCING INITIAL VASOSPASM OF ARTERY AND COLLATERALS CLOT ITSELF SECRETES SEROTONIN A STAONG VASOCON STRICTOR (Arge) 3 REACTIVE PHASE OF OCCLUSION PRESSURE HIGNER VESSELS DILATE UNDER INFLUENCE OF HISTAMINE LIKE BREAKDOWN PRODUCTS OF ANOXEMIC TISSUE (Bier) PRESSURE ABOVE ONSTRUCTION INCREASES BELOW OBSTRUCTION IT DECREASES (von Recklinghausen) CLOT GROWS DISTALLY COLLATERAL VESSELS INCREASE IN SIZE PROPORTIONAL TO BLOOD FLOW (Thoma Lewis ) PRESSURE LOWER Dngram i TREATMENT Successful mingement depends on the knowledge of the bove physiologic dat? and the pplication of hygienic measures to ad the natural adaptive mechanisms Attention to minute det ul is necessary (7) 1 Direct Surgery In the case of sudden embolization if espert viscular surgery is av ulable of less than eight hours have tran spired nd if the general condition of the patient will tolerate it embolectomy is the treatment of choice This is practical only if the obstruction is at the bifurcation of the horti or in the line irtery or femoral artery down to the poplitu al trei Popliteal cmboli ind those distal to it do better without sur gery Embolectomy may also be considered in the subcunor zilary arteries It is now considered wise to recommend anticoagul int therapy during the postoperative course The use of artennl grifts and by piss technics his mide surgical intenention fcnsi ble in some cases Large grafts replicing the abdominal 1orti distal to the real irtencs ·Chronic Arterial Insufficiency dication i at produced Of course mobiliza tion cannot be permitted Innng the stage when mussie gangrene a threatened Spreal ing or vers active infection also constitutes a contraindication As soon as this phast is passed we encourage carefully controlled and observed walking even when gangrenous toes or ulcers are present of a sharp line of demarcation has developed if there is indica tion of aggras aliant as a result of thts it should be dcfered until a later late 7 General Measures Supporti c me ISUITES should not be selected while focusing atten tion on a threatened lumb Problems 795001 with senous underlyin, diseases such as poli themi old thicum utic In art disease myo cardial infarction or diabetes mellitus should be treated appropriately CHROVIC ARTERIAL INSUFFICIENCI (h) WARNITI In addition to reflex huit If the limb suvises the acute occlusion 1 mentioned above if open Irsions are not pres state of ch onic arterial insufficiency often fol lo s Closure of an artery may also be very ent the ambulant patient may take wintul gradual The patient may then develop inter baths daily using 12 to 14 inches of water at mittent claudicabon necrotic ulcers or gan 99 to 100° F (36 to 35 C) for 30 minutes Drugs If skin lesions are present in grene dilators which shunt the blood to thin slin TREATMENT circulation may lxt of value to help heal these I Exercise in the chronic stage exercise is although it should be remembered that one important to encourage increased blood flos mas thus reduce the flow to the deeper tissue's and develop collateral vessels Walling is most Alcoholic Lescrages re probably as effective desirable but must be modified as to pace and as other means and well accepted by middle d stance by the capacity of the individual and aged and older people load in dilatation of bis affected circulation Idealls it should be at the large arteries the patient may sit or lic for a slo: enough pace to avoid claudication pain an hour with a heating pad over the lower part or fatigue When this does des elop the patient of the abdomen At the same time he may tuhe should pause and allow it to subside before re 1 tablet of glycerzi trinitrate 0 gm summg walking We have found that many under bus tongue This procedure shouki bo pat nts who at first could walk only a fex carried out one to three times dalis hundred yards or less base been able to in 5 Anticoagulant Therapy Long term ant) crease the ur walking distance up to several coagulant therapy is of special salue in po mules This may of cour e be in part due to tients with theumatic heart disease who have all other methods of therapy used Concurrently demonstrated any tendency to develop throm These include boembolic complications in a group of such • Tlte Use of Gravity The patient should patients which we have followed for from 1 sleep with the head of his bed elevated six to to 11 years we kale been able to reduce the en yht inches or it possible use an oscillating recurrence of such complications by about 80 bid Tii use of pillows for elesation is not sat ist actory The elevation may best be achies ed per cent (10) b, blocks (clock type) under the posts at the 6 Sympathectomy Sympathiectomy is only of value in rare carcfully selected cases it head of the bed gnes best results in the treatment of increasra 3 Vasodilatation () ALOIDANCE OF TOBACCO See above superficial vasomotor tone with ulcerations Increased blood flow to the muscles should not ·4 spism of severe degree is sometimes produced und gingrene muy result Such procedures should therefore be reserved for tests of vital importance This therapeutic approach is rarely justified (4) NERE BLOCKS The most effective method for releasing asospasm in the vessels of the skin and subcutincous tissues of the legs is the injection of prociine into the lumbar sympathetic ganglıı It frequently lasts for periods up to cight hours The results are apt to be less satisfactors when this technic is applied to the upper extremities Deep in jections such as these should not be given if the patient is on anticongulant therapy be cause of dinger of hemorrhage This pro cedure also has the disadv antige of opening up arteriovenous shunts in the provim il seg ments of the limb thus reducing blood flow to the peripheral tissues (e) SUVIPATUCCTOW Rarely sympathec tom (8) may be justified in the treatment of acute occlusion It has the effect of pro longing sympathetic interruption but the clis ndi intige of subjecting an often severely all patient to i major procedure (f) INDUCED I'rver Gener il vasodilatation occurs in fever This may be induced by in travenous injection of typhoid vaccine An initul dose of 5 million org inisms using ? dilution of 100 million organisms per ml is administered increasing by 3 to 5 million or ganisms with cach dose unless the previous to nction induces a chill or fever of more than 3° C The um is to produce a slight fever with out a chill This form of therapy is most help ful in cases of thromboingutis obliterans with murhed visospism 4 Maintenance of Tissue Viabılıty While the limb with major arterni insufficiency is wwaiting the development of collateral flow the tissue in jeopardy must be protected against traum mnceration infection dehydration and therm il dimage It is unwise to increase its metabolic rate and hence the demands for Arterial Diseases blood by the application of ultemal heat The incre iscd ou gen need cannot be met the deficits for ougen und other tissue foods in crease markedly and the tissues die On the other hand cooling produces i isoconstriction and decreased blood flow In general tlic af fected limb should be kept in an environment of 70 to 88° T Wet compresses ire contraindi cited because of their tendency toward cool ing and the heat loss bi ev porition further chills the part Gently coiting the liml) with an inert fit combined with antimicrobnl igents ind then uripping it loosely with cot ton wool will help munt un an ideal environ ment and protect it gunst mrcinition Cold or ice are used in selected prtients only when it has been decided to amputite Such patients are typically duhetics in poor condition and with marked infection or touc ibsorption from gingrenous foot When used in this way they releve pun recluce absorption from in infected irei reduce fuser ind illow tine for the patient to be prep ured satisfactorily for the operation This frequently includes the proper control of dubetic or curdic condition 5 Anticoagulants In prtients with emboli zition is for example from ile irt in wuri ular fibrillation antico gulants are riscul in reducing the incidence of further embol Thes also aid in the prevention of a tension of thromboses During the period of greith re duced blood flow in the affected limb throm bosis in situ in the capılları bed and small vessels together with thromboses in the sens is a const int threat which ide quite antico igulant administration will help combit G Exercise Under the heading of Idaptive Mechanisms tuis pointed out that collateral vessels develop in size ind efficiency propor tional to the rite of blood flow One of the gre test stmuli to incre used blood flow is the use of muscles Weight be irmg should be en couraged as soon as the tissue unbility wil tolerate it (9) Patients should walk van slowly slou cnough so that intermittent clau ·Case 1 Atherosclerosis Obliterans 7 CASE IISTORIES ATHEROSCLEROSIS OBLITER I\S The gradual accumulation of atherom ts in the intımı of arteries leads to narrowing of these vessels Blood flow to the muscles muy be sufficient when the person is at rest but when he walks it is not adequate Insufficit orygen is furnished for musculir contraction Intermittent cl iudication results This Is well illustrated by the following cost listory Case 1 Intermittent Claudication due to Atherosclerosis Obliterans Vote intense rubor of affected leg on de pendency Note intense pallor of affected foot on ck vation Conservative therapy was instituted this rest prin ceased in two weeks Ilus claudication distance has slowly improved and after sır months he was able to walk up to one half mile at a moderate pace A 60 year old railroad trainman had severe intermittent claudication in his left leg with color changes in the foot In the left figure note the intense rubor that develops in the affected leg upon dependency Intense pallor develops in the affected foot on elevation as shown in the night figure These color changes are characteristic of arterial insufficiency Pulses and oscillometric readings were as follows PULSES RIGHT LEFT Posterior tibial 2+ 0 Dorsalis redis 0 Femoral 2+ OSCILLOVETRIC READINCS 10 00 Ankle 25 01 Calf 35 02 Thigh 35 04 2+ As the disease progresses some vessels lx come completely blocked by atheromns In others a thrombus forms which suddenls in terferes with the flow of blood When ras recene insufficient blood even at rest death of tissue results in the presence of diabetes mellitus this process takes place at a moru ripid rate The small branch vessels as well as the large main trunks are frequently damaged wel infection often complicates the picture very fant Foot Case 2 illustrates these fintures ·6 Arterial Diseases weir heavy underwear and stadium boots He should be cutioned never to put heit 21 any form (including du thermy) on the in volved limb (see parigraph 4 under "Acute Occlusion) He must wod visoconstrictor drugs such as epinephrine ephedrine benze drinc dexedrine or ergot derivatives le should alu ays keep the affected limb below heurt Icycl be expected from the operation In patients withi normal or decre used vasomotor tone the results are usually dis appointing Sympathec tomy should be reserved for patients who have not done well on the conservative regimen outlined above including the absolute prohı bition of tobicco The regimen is valueless unless the patient discontinues the use of to bacco 7 Care of Ulcers Necrotic ulcers must be cured for with greit gentleness Debridement should be done minutely and at miny sittings Amputation of necrotic toes often lewes a nonhealing stump Hot souks must be strictly worded for the reasons given above The temperature of salıne souls used duly should be from 90 to 95° F (32 to 35° C) Wet dress ings are too cooling Strong chemicals only add to the necrosis Mild intimicrobial oint ments with 1 wide spectrum are best such as aureomycin ointment 3 per cent Furncin sol uble dressing is excellent of the physician is alert to shin sensitization These ointments have wide spectrı are relatively pontouc and kill many saprophytes as well 8 General Hygiene The patient must zvoid chilling in cold wenther he should PROGNOSIS The outlook for patients with chronic urte rl occlusne disease is much better than commonly accepted by the medical profes sion provided that these patients persist in their adherence to tlic regimen outlined above This muy mean 1 matter of veurs rather thin weeks and the patient must be oriented re garding the long range approach to his prob lem it in early visit Many patients with major occlusions even of so lirge Wessel is the lower abdominal aorta have been restored to in active life and are in good health a decide or more later Some ire able to walk long distances at 1 slow pace resume Inborious activity and sports such as golf which do not require the running involved in tennis or squash SUMMARY If a sound knowledge of physiologic princi unble and the embolus is at the level of ples is applied nature will provide many ad the midfemoral artery or proximal to this aptive measures to produce collateral blood point flow Walking long continuous distinçes at Surgical procedures are usually unnecessary 2 slow enough pnce so that pun does not in the treatment of cirly lesions of thrombo irise is most importint Tobicco must be ingutis obliterans and atherosclerosis Con climinated Gruity should be utilized to aid servative management guies good results in blood flow and clevation of the affected ex most of these cases In adı inced cises of gin tremity should be loided Warmth must be grene imputation may be necessary. This emploved only is outlined above Vasodilat should be regirded is i defcit of conseri itse ing drugs are frequently not lielpful and may measures for of numerous CIUSS be harmful After surgers the patient should be given Surgical procedures should be considered the benefit of the sume sound physiologic mun for inviding tumors and for aneurysms With agement used for medical cases The opposite in the first few hours ifter embolization sur extremity which is frequently involved should gery is indicited if ? well truned teim is be given meticulous attention ·Case 2 Atherosclerosis Obliterans C Five months later D Heel shows cle in granulation The remainder of the foot was red suollen Ind cold + PUSES RICIT LEFT Po terior tibial 0 0 Dorsalis pedis 0 0 Popliteal 0 0 Femoral + OSCILLOVETRIC READINGS Foot 0 0 Ankle 03 04 Calf 04 04 Thigh 12 10 The patient w is instructed to stand by the side of her bed and take a few steps several times a day This is as gradually incrersed and at the end of onc cek shes alled to the bath room with the help of two nurses An oscillat ing bed was set for a dowissing of 15 degrees and no upswing above the horizontal Thor foot was covered with antibacterial ointment and wrapped in cotton It was dressal dus At the end of three mocks she was able to walk every hour for five minutes with help The temperature was defencscent Her nir cotic addiction was reduced She was sent home to a distint city to con tinue her treatment in collaboration with her personal physician An oscillatın bed » is ·8 Arterial Diseases Case 2 Atherosclerosis Obliterins, Diabetes Mellitus, Hypertension (170/100), Gangrene of Left Foot A Blich gangrenous ulcers B One month later Mrs R (The New York Hospital # 705-427) aged 69 presented the above com plications Her drabetes had been treated for 18 years Fre months prior to admission the left fifth toe had become infected It became gingrenous and was imputated The wound did not heal A spreading cellulitis developed The surrounding area became black Necrotic areas developed on the lateral side of the heel and on its posterior surface The patient was septic She was in great pun and had become addicted to narcotics Amputation of the leg had been advised by several consultants She had been in three different hospitals in an effort to save the leg She was admitted to The New York Hospi tal on March 13 1955 She had not unlhed for the previous six months Examination showed extensive gingrene of the left foot Black cir culır areas were present at the heel tıp (2 cm in diameter) lateral heel (3 cm ) and lateral interior surface (9 cm ) and there was 1 large black slough over the stump of small toc imputation site is shown in Figure A ·11 Case 2 Atherosclerosis Obliterans whr. Level w G Eleven months healing complete 11 Section of femoral urters of similar patient COSTIENT This case illustrates the ability of the tissues to heal even with most advanced gangrenous lesions gnen sound therapy and adequate time It may be argued that this was too long a period for most patients and we agree but this patient desired to save the leg at all costs and it was possible to demonstrate that this could be accomplished Figure H 15 another illustration of athero sclerosis This is a section of a femorul artery stained with hematorylın eosin It is not taken from Case 2 but from a similar patient who came to autopsy The internal elastic lamına is interruptel at many points A large portion of intima is replaced and cos cred by n bu alımzed ntero sclerotic plaque Some are is of this phique shou diense collagen material Other art is a mare cellulur and shou a looser tetture The media is irregular in thickness Incul necrosis lus ocmitted in some is where the smooth muscle has been replaced by col Hagen In the center of the section is 1 miss of cosinopılıc material disintegrited red cells and piztelets Occusionally the diseast progresses vers rpidly in large vessels ind occlusion occurs suddenly at 1 high level This is illustrated in Cases 3 and 4 ·10 Arterial Diseases Case 2 (Continued) E Seven months F Nine months obtuned She slept on it and remained on it during the day except when walking At two week intervals and later at one month inter vals she returned to New York for follow up visits which included gradual debridement One month later the large necrotic lesion over the interior of the foot hus localized is Slen in Figure B The necrotic arers liquefied and slowly they were replaced by granulation tissue In Figure C trhen five months after conservative treatment wis started the blick necrotic urers hrve sloughed and grinul ition his started The ulcer on the posterior tıp of the heel las completely epithelialızed Figure D is a close up of the later al heel shoxing clein grinulation Seven months after the first visit all necrotic weis were replaced by grimulation tissue Thc fourth left toe was loose and with out nerve innervation The fourth and fifth metatarsal bones had sloughed away in the necrotic debris Therefore this toc was re moved during one visit This required no anesthesiz ind was practically punless (Fig E) Epithelialization took place (FIG F) Final herling 1 is complete 11 months after the stort of ambulant ther ipy (Fig G) ·0 13 Case 3 Atherosclerosis Obliterans Ambulation was urged as soon as the de He had great difficulty walking He reported cica e in pain would allow it to the emergency clinic and was sent to the raz studies were cirried out A lernt Vascular clinic by heelchair Nel of the low crabdomen reelled a calcifical On examination ke uas found to be acutely plaque in the lower alxdominal port1 The ill In a horizontal position his legs and fect 13 studs is shown in Ligure C Note the Here white and cold as shown in Figure A A calcification in the alxdominal aorta cyanatic rubor deseloped in both feet when The results of injecting contrast med into they were in dependency (Fig B) o picture the aorta are shown in Figure D This is in wa taken with the legs in election because Tray AP sew and it shows block it the of dinger ta thus patient who had such marked bifurcation of the nort 1 nurowd chand in arterul insufficiency Pulses and oscillometric the right line and great ik sclopment of col readings were as folloss lateral vessels Aote the complete bloch age of PULSES RIGIT LEFT one slac artery and narrow ing of the other at the aortic bifurcation Posterior tibia) 0 0 Dorsalio pedis 0 0 A consen atise regimen i 18 decided upon Pupliceal 0 0 His walking distance slowly increual intal Fermoral 3 0 he was able to lase bathroom privleges le OSCILLAVETTIG retumed to work This required right Diours ? ΗΣ ΑΣΥΛCS clay on his feet Ile was instructed to protect Foot 0 himself against chuling in the winter ho Ankle D "ears heavy underwear wool sochs and Calf 0 stadium boots He has been crytioned to avoxd Thugh 02 02 heat to his feet Pallor on elevation of het ++ After six years he now walls two to Rubor on dependency three continuous miles slowly ench das of feet 4+ - The collateral blood Box in lus legs has in cressed enormously as evidenced by the ter He was hospitalized at once He was placed ture and warmth of lus siin llis oscillomctric on an oscillating bed it was set so that the readings are now feet did not nse above the horizontal position because of the marhtd pallor when the feet OSCILLOVETRIC scre elevated above this level The down READINGS Ricart LEET sking for the feet was set at 15 degrees Foot 01 02 Ankle He had smoked 40 to 60 cigarettes duly 04 08 Cavs 00 Tobacco was interdicted It required a su 08 Thigh 08 10 preme effort of will power to gue up this addiction but he succeeded He has not re His generalized atherosclerosis obliterans sumed the use of tobacro for the past six and hypertension have progressed however Years His right ulnar artery is not palpable and the Reflct heat, in the form of a heating rad radual artery is seal Hisle brachial artery is Was ipplied to the groin an alternate hours Al partly secluded However the collateral flow coholic beverages were encouraged Sublin Is so good that he is symptom free in us arms qual notrogh cerin was given twice daily and Because of the occlusie descasc blood pres Later once daily sure readings which hał ranged is high as 220/110 can no longer be obtained 4+

·12
Arterial Diseases
Casc 3 Atherosclerosis Obliterans with Occlusion of Bifurcation of Aort?
A Legs show pallor in horizontal position
B Rubor of legs in dependency
Cray of later al abdomen
D\riy of abdomen AP vien
Mr A P is a 58 yeur old watchman He
has been employed at The New York Hospital
for many years and had enjoyed good health
up to the time of this episode ercept for a
simptomless hipertension One cold winters
day while on duty outside the hospital en
trance he suddenly expenenced intense pain
in his back His legs becime nunb und cold

·Case 5 Atherosclerosis Obliterans with Gingrenous Ulcer, Ilciled by Conservative Therapy Two months later Mote black necrotic tissue Mr MW is a 65 year old automobile dcaler who entered The New York Hospital (#669097) in October 1953 The diagnosis was atherosclerosis obliterans wath occlusion of both popliteal arteries and a gangrenous ulcer on his shin which measured 7 by 3 cm It is well shown in the accompanying photographs He was a severe hypertensive (220/ 130) He did not have diabetes Vascular er amination showed PULSES RICII LEFT Posterior tibial 0 0 Dorsalı pedis 0 0 Pophteal 0 0 Femoral 2+ 2+ One year later OSCILLOVETRIC READINGS Foot 0 Ankle 03 Calf Thigh 25 Pallor on elevation of feet 2+ Rulor on dependency of feet 2+ 0 02 06 30 04 2+ 2+ when in bed The skin broke down over the outer malleolus at the point of pressure A second large necrotic ulcer formal Crduith both ulcers granulated lle visited us at monthlı intervals After six months all tissues appeared healthy but the two ukers had not epithelialized They were covered with pous dered blood cells a hard coagulum formed He was seen again in six months Epithelium had grown across and the skin wys intuct lie continues to be well He walks one mile (cha day at a slow pace as a therapeutic incisur! The upper left figure is a sicu of the lower leg Note the black necrotic tissue The upper 11, ht figure was then two months later The necrotic tissue has slougled A deep punched out ulcer is present which shows granulation The bottom figure was taken one jtar later The area is completely heaks He had been fearful of walking for several months Ambulation was started at once The oscillatin, bed warm tub baths and reflex hent were employed He remained in the hospital for three wechs He continued his treatment at home The health of the tissues of his legs improved slowly Tht necrotic skin at the site of the lesion was dissected off He was accustomed to crossing his feet ·14 Artenal Diseases ige 0 0 0 0 0 Case 4 Calcification of Abdominal Aorth with Completc Obstruction Mrs M s 1 housewife who was only 35 jeurs of at the time of the episode to be described She bid enjoyed eicellent health She was i proficient athlete ind 7 vigorous golfer Her menstrual pattern w is normal in every respect One day, while playing golf she sturted to walk up i hill Suddenly her legs would not hold her ur She experienced sharp pun in her back and thughs She fell to the ground Subsequently she was removed to 1 hospital On examination her legs were cold inci pulseless Oscillometric rendings and pulses were as follows PULSCS RICHIT LEHT Posterior tibul 0 0 Dors ılıs pedis Poplitent I emoral Lateral radiograph showing OSCILLOVETRIC extreme calcification of abdom READINGS inal zort z opposite bodies of I oot lunbir vertebrae one two and Ankle three Chif Thigh 01 02 Pallor on eles ntion of feet site of murnl thrombus completely obstruct Rubor on dependency of ing the norta fcct 4+ Studies of calcium and phosphorus metal She wis placed in in oscillating bed with olism were normal A complete endocrine 25 degree upsting ind i 15 degree down studs kis normal Blood cholesterol was 195 swing Tobacco was interdicted mg which she obered with difficulty but suc She left the hospital aftur two weeks At cessfully Reflex heat in the form of a heating home she gradually incre used her willing, pid to the abdomen w is applied at alternate distince She is now able to walk any distince hours She was cautioned against applying up to tho miles at 1 moderate pice heat to her feet Walking was commenced The acute occlusion occurred in 1919 At first it was painful to even bear weight but She has been followed crefull during the soon she was able to take a few steps each Il intervening yeurs The only il]ness that is hour worth noting is hyperthyroidism wluch diesel The illustration shows a radiograph of oped in 1951 und wuch responded well to the abdomen in the Internl position Extreme subtotal thyroxectomy calcification of the abdominal aorta is present When sussels to segmentul artis ir oc cluded necrosis of defined areas mn follow opposite the bodies of lumbar vertebrae ont tao and three This undoubtedly was the is in Case 5 0 0 0 0 0 0 in order ·Case 7 Atherosclerosis Obliterans Case 7 Atherosclerosis Obliterans Dsabetes Velistus with Gingrenc of Large Toc Separation of toc Gmgrenous toes NE Four months later following conservative therapy seen in the Mr P VCD The New York Hospital -783820 zs a 58 year old municipal worker lle presented himself with gangrenous tor's as upper left figure His other leg had becn amputated one sear prepously at an other Clinic Alc was able to wall well with his artı fcial leg but had taken to bed when his tocs poned him He had an occlusion of his fem oral artery in Hunters canal He was trcited as in ambulant pabent and not admitted to hospital The diabetes was controlled by Onnase and dict Each hour walled for a minimum of five minutes gave up the use of tobacco Furacın solt dressing was applied July to his tocs necrotic toe separated at a lue of dema tion as shown at the upper right The 1 was setered with scissors Ile was encour, to well and reported for weekly dehrden Complete healing was obtained as shon the bottom llustration taken four in later

·16
Artenal Diseases
Case 6 Atherosclerosis Obliterins, Diabetes Mellitus, with Gungrene of Large Toc and Foot
Gangrene of large toe ind foot
After conservative therapy
Mrs Gis68 year old Italian born house
wife She presented herself with a black gin
grenous toe ind foot as seen on the left She
had been confined to bed for five months
Examination showed occlusion of the
pop
Irteal artery Although the patient was brought
in by ambulance weight beiring was started
nt once
She was not admitted to the hospit il but
was trented as an out patient She was in
structed to stand up and walk every hour
Furcin soluble dressings were applied duly
The diabetes was controlled with insulin
She reported each week for debridement
Walking was increased duly In a months
time she was able to carry on her normal ac
tivities The necrotic tissue was dissected free
at the lines of demurention
Herling was ripid and complete follow
ing conservatrc therapy

·Case 8 Arteriosclerosis
19
Radiograph of thigh showing calcifi
crtion of the femoral and tributary ar
terics
Lateral view of knee show
ing calcification of papliteal
artery
Lateral sicw of foot and
ankle showing calcification of
posterior and anterior tibial
arteries

·18 18 Arterial Diseases ARTERIOSCLEROSIS MONCKEBERGS VEDIAL TYPE Arteriosclerosis which involves the intımı process does not reduce the cihber of the ses of uteries must be carefully distinguished stl and is i bengn process Cise 8 illustrates from Monchebergs sclerosis which concerns thuis the modul Iyer of the vessels The litter Case 8 Arteriosclerosis (Monckebergs Medral Type) with Extensive Calcificntion without Obstruction This 77 year old mun has extreme calcifi interior tibial arteries No myor vessels ire cition of ul large arteries They can be seen occluded All pulses ro palpable Oscillo clearly outlined on the radiographs The top metric reidings ure norm ul He had intermit figure shous cilcification of the femoral and tent cluudication in the calves ifter wing tributary arterics The lower left illustration five blocks This wis belici ed to be due to 15 lateral view of the knee showing calcifici interference with the circulation in some tion of the popliteal artery The lower right mmor brunches supplying the oilf muscles figure is a later il vich of the foot and ankle On consentive therapy lie incre used lus ind shows calcification of thic posterior and 15 aling distance to one mile ·21 Case 9 Thromboangutis Obliterans Gangrene of large toe Complete healing Smoking was interdicted The oscillating bed was set at 0 degrees upsuing 15 degrees downswing Fever therapy was given using intravenous typhoid vaccine every third to fifth day The foot was dressed darly The left figure was taken one month later when con siderable improvement had occurred It was decided to ambulate this man and have him walk with crutches His intense pain was re lieved After one month of this he was al lowed to bear weight This was the first case of gangrene in our senes in which weight bearing was tried He not only tolerated it well but improvement was more rapid le was discharged after two months hospitaliza tion The toe had not yet haled but it was clean and granulating He was seen thereafter at bwechly inter vals Two months later healing was complete He returned to his job as a truck drives te has been seen twice yearly for the past seven Fears when as shown in the right figure com plute healing las taken place llis last exam nation was in January 1959 The foot was warm pink and dry Thc toc was intact Ilc can walk any reasonable distance at a moder atc pace without claudication ·20 Arternal Diseases { THROMBOANGIITIS OBLITERANS (BUERGERS DISCASE) This is in acute or subicutc infl ummatory is duc to z peculiar constitution il idiosyncrası disease involving the veins arteries, and to some substances in tobacco is yet not fully nerves It occurs in young and early middle understood nged ndults Until recently it u is largely con Frequently episodes of phlebitis occur fined to males but we are now seeing it more months or cien yeurs before arteries are oc frequently in females This is probably be cluded In about 40 per cent of all patients cause of the increased ind prolonged use of phlebitis occurs at some time The disease tobicco by women then goes on to involve digital arteries most In our elperience the disease occurs only commonly in the tocs If the use of tobicco is in users of tobacco It subsides when tobacco not discontinued Irrge vessels such as fem is interdicted If smoking is resumed even or ils ulics riduals and ulnars eventually be veurs later it returns It does not fit the come involved linally visceral vessels uc usually accepted criteria for in allergy nor often occluded such as coronıry and mesen is it entirely due to the insoconstricting in teric arteries fluence of nicotine We feel that this disease Case 9 Thromboingntis Obliterins, Gangrene of Large Toc, with Healing Mr P II The New York Hospital #511287 admitted in July 1919 was a 38 year old truck driver The diagnosis was thromboang? atis obliterins with gingrene of the right first toe and with occlusion of the right popliteal artery and of the right ulnır artery He lid suffered from severnl episodes of superfici l phlebitis during the prior two years for three months the right foot had been incrcasingly numb and punful A crimp consistently developed in the right calf after walking about 100 vards There was constant burning pain in the right first toe which be cime cold and cianotic He had been hos pitalized elsewhere Ile bad received procune nerve blocks and intravenous procaine and the use of the oscillating bed The lesion becime progressively worse Ilc had been bedrudden for two months On admission it was found that the night first toe was gangrenous (see the left figure) The foot u is cold and pulseless Pulses and oscillometric readings were as follows PULSES Ricort LEFT Dorsalis pedis 2+ Posterior tibral Popliteal 2+ Femoral Week 3+ Radial 2+ 2+ Ulnar 2+ o 0 0 + + + + + + 0 OSCILLOVETRIC RE ADICS Toot Ankle Calf Thigh 0 03 06 12 06 35 35

·23
Case 10 Thromboanguitis Obhterans
Gangrenous ulcerations
Close up showing necrotic ulcerations
LO
One year later
Section from another patient with sunılır
discase

·22 Arterial Diseases Case 10 Thromboangulis Obliterans MrJS (The New York IIospital #662892) 1 35 yeir old public school janitor was admitted to the hospital in August 1953 The diagnosis was thromboingitis obliter ins with gangrene of toes and fingers The two top figures show the gingrenous ulcerations The digital vessels in these irc is were thrombosed The top nght figure shows a close up of the toes with necrotic ulcerations Seven months previously he lind developed bilaternl throm bophlebitis uluch had subsided after rest in bed for one month Two weeks prior to ad mission his toes bec ime painful cold und blue The left index finger becime swollen cold and ulcerited The right index finger soon became similarly cold and ulcerated These ulcerations had developed at the sites of minor abrasions Examination showed partial bloch age of the right rudal urtery and both ulnar arteries The dors als pedis and posterior tibrul pulses were absent Oscillometric readings were zero biliter ully below the knees Despite warnings the patient continued to smoke Both first toes developed gingrene A bilater al sympathectomy was done and is is the usual cyperience no improvement re sulted until the patient give up tobacco Wilhing was sturted Healing was then rapid The necrotic tissue sloughed on the toes and fingers He has seen at wcchly inten ils bs Dr Ellen McDevitt in the clinic where his Hounds were dressed and gently debnded The patient returned to work Dressings were necessary for an additional six months before healing wis complete He has been followed at frequent inter ils in the clinic The lower left illustration was then one ver Inter Healing his followed the cessation of the use of tobacco together with conservative measures At present he has been followed for three and a half years since complete heal ing Oscillometric rerdings have incrcised mirkedly Hands and feet are warm pink und dry He works a full day performing lus full duties as i janitor He wills long des tinces The lower right figure is a microscopic scc tion from another patient with a similar dis esc The eurly lesions in this disease are thought to be in acute inflammation of all layers of the walls of veins and arteries Thirombi de velop over the inffumed are is Thus section of artery shows the internal clistic lamını embedded in 1 thrombus in various stages of organization Some rers are recent and some fresh The dense blach are is are hemoglobin pigment Note the cellular se action in the adventitia

·25
Case 12 Thromboangutes Obliterans
Case 12 Thromboangutes Obliterans Quadrilateral
Ulcers on right second and thud fingers
Close
up
of ulcers
This 26 year old robust carpenter had
signs of artenal blockage in all four extrem
ties He was a heavy cigarette smoler The
hands were red on dependency and pale on
elevation The left photograph of both hands
shows ulcers on the nght second and third
fingers The right photograph is a close up
of the right hand and shous datus of this
ulcers The rul pulso is blocked on the
nght Oscillometric readings are greatly re
duced in the wrist are zero in the hand and
also are reduced in the lift Innd and wrist
Dorsals pedis puises arc absent

·24
Arterial Diseases
Case 11 Thromboangutis Obliterans of Both Lower Extremities
Close up
Ulceration of right foot and large toe
of ulcerated large toe and necrofie
ulcer on dorsum of foot
Allen test
This 33 year old min lid hrudin imput?
tion of his left leg it age 19 froin throm
borngutis obliter ins He resumed smoking 14
yeurs Inter The disc ise returned md he de
vcloped g ingrenous ulcers of his right foot
ind large to as seen in the upper left figure
and changes in the vessels of the hands the
urper right illustration is a close up of the
ulcerited large tot and necrotic ulcer on the
dorsum of the foot The bottom figure is in
illustration of the Allen test The photograph
shows the ridial arteries blocked off by the
cammers thumbs One I ind is pink show
ing patunci of the ulnir irters and pilmir
irch The other hand is prle indiciting ?
block age of the ulnar arter

·27 Case 14 Embolus ARTERIAL EMBOLIZATION Large clots form in the auricles or other off and flou out into the systeinic ciruulation chambers of the heart of the heart is fibrilla lodging in the bruin viscer? or extremities ting or if it is deformed because of mitral When a large clot ocelucks the l»ſure ition stenosis or another cw e Clats may also fom of the abdominal aort it is hominis over damaged are is of endocardrum is in snddic embolus" Such CSC is illustrated in myocardial infarction These clots mas break the following histor 1 Case 14 Embolus to Lower Extremitics Necrotic black toe and dependent rubor Toe sepirited during a dressing Complete healing Vrs M S The New York Hospital 1954 At that time she dc cloped soucre an #696317 had an embolus of the lower abgni pectoris Thrs gradually increased It dominal aorta and gangrene of the foot. This culminated in an episode of severe substerna 51 year old factory worker had been well until pressure which led to admission in another SHT Weeks before her admission in November hospital A diagnosis of myocardial infarction

·26
Arterial Diseax =
Casc 13 Thrombongitis Obliterins in a Woman
Dependent rulor of ffected
foot
Granulatmg stump of num
ber four toc
This 39 verr old housewift smoked 60
cigarettes duly rour se irs ago slie brusc
her left foot ind mulcer forincd on lier left
fourth toc Ilic ulcer would not lie il and the
toc w is imputited ud i sumpithectomy was
performed Ili stup would not hul sho
Ind not been told to stop smoking Thuis in
terdiction w is enforced and faciling followed
The left figure shows intenso dependent rubor
of the effected foot compared to the normal
color of the other foot The right figure is ?
close
up of the tocs showing granuliteng
stump of fourth toc Pulses ire ibsent in the
foot Oscillometric roudmys ir reduced up
tlic leg

·27
In Case 14 Embolus
ARTERIAL EMBOLIZATION
Large clots form in the auricles or other off and flow out into the sistemic circulation
chambers of the heart of the heart is fibrilla lodging in thc bruin visceri or cutremities
ting or if it is deformed because of mitral Wien 1 lirge clot occludes the bifurcition
stenosis or another cause Clots may also form of the abilominul lorth it is known as
over damaged areas of endocardium is in "siddle cmbolus Such 1 Cisc is illustrateel in
myocardial infarction These clots may break the follos ing histon
1
Case 14 Embolus to Lower Extremities
Necrotic black toe and dependent rubor
Toe separated during ? dressing
Complete healing
Mrs M S The New York Hospital
#69617 had an embolus of the lower ab
dominal aorta and gangrene of the foot This
51 year old factory worker had been well until
six weeks before her admission in November
1954 At that time she developedl se cre an
gina pectors This gradually increased It
culminated in an episode of severt substemul
pressure which led to admission in another
hospital A diagnosis of myocardial infarction

·pun in 28 115 established Anticoagulants were not given on the fourteenth day while struining on a bedpan she developed a sudden her left leg Thu leg rapidly became cold and blue She was then trinsferred to The New York Hospital Examination showed cold pulseless cy? notic Jegs Femoral pulses were absent Our dingnosis was embolization of the lower ab dominal nort? from mural thrombus secondary to myocardit infuction Trentment consisted of anticoagulant therapy with the use of an oscillatıng bed and reflex hcat The legs became warmer but the left large toc became black and mummified Collateral flour dueloped down into the foot All are is be cime pink and warm except for the black toe The patient was ambulated and discharged She came to the clinic weekly where she was treated by Dr Ellen McDevitt In March (four months after her embolic phenomenon) 1 Arternal Diseases the necrotic toe was gently twisted off with a thumb forceps The stump quickly epithelial ized A follow up for three ind i hulf years shous continuous improvement in collater il circulation She works at her factor job as before The accompanying photographs show the necrotic black toe and the dependent rubor The pruent was entouraged to will long dis tances slowly Arterial flow continued to im prove She was treated as in out patient at weekly interı ils Perfect healing was obtamed If such a patient is seen within 1 feu hours after embolism blocking the aorta ılıc or femoral arteries of the lower extremities or the subclavın axillary arteries serious con sıderntion should be given to immednte em bolectomy The genernl condition of the patient must be considered before such an operation A recent myocardial infirction is usually considered as a grue surgical risk BIBLIOGRAPHY 1 Foley W T VeDevitt E Tulloch J A Tunis mechanischen Bedingugen der Blutumlaufes Vind Wright I S Studics of isospasm The Terchons Arch f path Anat 95 294 1894 use of glyceryl trimtrate as ? dugnostic test of 6 Lewis T The adjustment of blood ft to the peripheral pulses Circulation 7 847 1953 affected limb in arteriovenous fistula Clin Sc 2 Rapport 1 Green AA and PGC I B 4 977 19:10 Serum vasoconstrictor (se rotonin) IV Isolation 7 Foley IT and I night I S Medical manage and charucterization J Biol Chem 176 1243 ment of arterial occlusion and thrombophlchitis 1948 Vod Concepts Cirdion is Dis 22 102 1953 3 von Rechlin hansen Hundbuch der allgemeinen 8 Narde vand Sasen A The priman influence Pathologie des Kreislaufs und der Ernahrung of basal suscular tone on the development of postocclusive collateral circulation and in selit Stuttgart Verlag von Ferdinand Inle 1893 p 117 ing patients for sympathectom Im J V Sc 209 478 19:15 4 Bier A Ilici I Der arterielle Kreislauf Die En 9 Foley | T The treatment of gingri ne of the trstehung des Collater kresst wufs lichoss Arch legs by walking Circulation 15 699 1997 f path Anit 147 256 1897 10 night I S Symons C and VicDevitt 5 Thoma R Ueber die Abhangigkeit der Binde C Further experiences with long term antı gewebsneubildung in der Arterienintima von der edagu! int teripy Arch Int ved 95 197 195, ·2 Venous Diseases ures 1 VENOUS INSUFFICICICI Patients with venous insufficiency like it drains are then subjected to increased pres most patients with diabetes cannot be cured sure The usual drainage of fund from the but they can be maintained in good health tussucs is interfered with llaste products ac provided they follow certain hygienic meas cumulate in the tissues especially about the ankles Red blood cells leak out into the tissue In the upnght posture a column of blood spaces and disintegrite Thicy fcase behind extending from the nght auricle to the ankle their iron pigment which stains the tissues a may excrt as much as 100 mm of mercury of rust color Tissue cells become atropic mr hydrostatic. pressure if this enormous head croorganisms thrue and 1 condition known of pressure were transmitted directly to sur as "stasis dermatitis" occurs Kuid accumula face veins they would rupture Counteracting tion results in intracellular edema Tinally this are valves inside the seins and the turgor the shin dies and ulceration follows of muscles and tissues outside The ideal treatment would be to replace Some persons arc bom with weak venous the defective sales This is a project for the valies Rarels they may be absent in attain future At present all attempts to do so laic venous segments such as the communicating failed owing to the case of thrombus forma veins between the deep and the superficial tion at the site of the prost!ıcsis systems of the legs In others the vein walls Elevation of the log reduces the schous are weak and after years of pressure they pressure to zero or below and results on ripid sag outu ard at the sites of the valves pre venous drainage This utilization of the aid of senting the leaflets from closing tights and gravity can usually be accomplished for one thus making them incompetent These are the third of each 24 hours by having the patient key factors in the development of varicose sleep with the fect cles atcd sex inches by veids which occur frequently in some families placing blocks under the legs of the bell This After years of standing the sales become de is more comfortable and more effective than fective under the strain The hydrostatic pres elevating the legs on a pillow or raising the sure is then passed along distally to the next mattress ale In time it too may give way When The increased enous pressure on the sur the pressure is communicated to a surface vein it becomes tortuous or varicosc upon face of the legs can be counteracted by the stundin, Reversal of direction of blood flow compression of an ciastic support Ideally this may occur in such a vein The enules which support should just balance the increased pressure Empirically it has been found that 29 ·30 this may usually be accomplished by exerting 50 mm of mercun pressure at the foot and ankle gridurlly diminishing to a pressure of 20 mm just below the knee To do this many measurements are needed The circumfercnce should be mersured at one inch intervals from toes to Ince Stockings that come above the knee often bind the popliteal space and give 1 tourniquet action This occurs especially when the knee is bent knee length stochings are usually pref erable The set cre effects of venous insuffi cicncy manifest themselves in the lower half of the leg It is in this area that compression is needed Caution must be used in the use of compression when there is evidence that the patient is also suffering from impured urternal circulation Here the physician must use good judgment weighing carefully the relative seriousness of the two conditions Elastic girdies and round garters impede venous flow and must not be worn in this condition Walking in teater or silinmig exerts ? beneficial effect on the venous flow The u ter pressure is mrumum at the feet and less and less 11р the body--ideal for clearing the tissues of stagnant lymph Patients suffering from Venous insufficiency almost uniformly report great improvement after 1 summer of swim ming Postphlebitic Syndrome During the acute phase of thrombophlebitis the vahes of the involved veins often become enmeshed in the infiammatory action and thus are deformed or destroyed Later after varying periods of time the absence of these valves minifests itself in the invoked leg bs the signs of chronic Venous insufficiency This damage is reduced if the patient uses an elastic stocking or sup port from the first day of ambulation Walking with 7 well fitted elastic stocking in place is beneficnl to the leg with renous Venous Diseases insufficiency The muscular contraction gives a pumping action to the deep veins and sup plants the dynamic action of valves Standing still however is z great strun on the venous for Sitting with legs dependent for long periods of time is to be noided We instruct patients to walk about every half hour when on long pline trun or automobile trips This aduce also pertuns to long meetings card games or other periods of prolonged setting For months and even years after an attack of phlebitis the legs are subject to episodes of pains ind aches These are most apt to occur during a full of barometric pressure and en able the patient to forec ist 7 period of bud wenther Patients are apt to worry and fear that there has been a return of acute phlebitis llc instruct them to elev ate their legs markedly and pply hot moist packs Such pain often dis appears very quickly and should be relieved in a period of at most two hours If it lasts longer than this 1 recurrence of phlebitis should be considered and 1 plus sıcıın should see the patient Sclerosing by the Empty Vein Technic Sclerosing injections have been employed for many years by the profession to obliterate de fectue superficul seins Various substances have been used They are usually effectue for 1 few months but recinzation takes place ind the vir sooner or later returns Local pigmentation frequently occurs it the site of the injection We use ? technic of injecting trices after they inue been emptied of blood In this munner usually no thrombus is formed The intimi of the vein becomes inflımcd The vein contracts immediately after injection The walls of the vein grow together and the vein becomes a fibrous cord If proper clastic stock ings are worn thereafter there is less tendenci for 1 ces to recus ·Venous Insufficiency SURGICAL MEASURES It is beyond the scope of this book to enter into a dissertation of the rous surgical measures employed In a general way it may be stated that the im of surgery is to elimi nate the incompetent veins that penetrate the deep fascia and connect the deep senous channels with the superficial seis (7) The main veins that do this are 1 the great saphenous vein which extends from the groin down the inner side of the leg to the ankle 2 the short saphenous i ein which extends from the popliteal space down the outer side of the leg 3 several short verns in Hunters cinal 4 31 communicating veins just about the inner and outer mulicolus 5 it times other communi citing seins along the forc leg When 1 superficul ven is connected to 1 deep vein si i communicating on that is in competent it can often ly demonstrated that the blood flows in the opposite direction lien the prtient is in an upright position Celul ligation of these incompetent sems flush to their point of origin from the deep vean is the fundamental im of surger Tlit tritication of diluted varices by such mesures as "stripping" is usuall done as well It is our experi etice that patients who wer well fitted elastic stockings after surgers get the last results

·32
Venous Diseases
Case 15 Varicose Veins
Dilated varicose veins
One year follow up
Mr WG (The New York Hospital
#536125) is in 80 year old executive He
noted varicose veins about 20 years ago These
gradually increased in size until they became
mukedly enlarged throughout the long and
short saphenous systems as shown in the left
figure
A fitted elastic stoching was prescribed with
graded pressure A series of three injections
of Sylnasol was given at monthly intervals
using the empty vein technic The right figure
was then one year later Note the disappear
ance of the enlarged veins He must continue
to wear his gradient elastic stocking to wod
recurrence

·33
Case 16 Varicose Veins
Case 16 Varicose veins, Strsus Dermatitis, Ulccration
VIL
Before treatment
Six month follow up
Mrs Ek is a 50 year old housekeeper
Prominent varicose veins developed at age 25
They gradually increased in size Pigmenta
tion formed at the ankle together with a
plexus of seins The skin of the left inner mal
leolus became rough and itchy About tho
years ago a painful ulcer formed
The left photograph shows the prominent
varices pooling pigmentation stasis eczema
and ulcer formation of two years duration
"The flow of blood in those dilated veins was
retrograde in changing the posture of the
patient from the reclining to the standing
position
Fitted elastic stockings with graded pres
sure were presenbed The defective icins
were obliterated, using the empts sein tech
me In particular one communicating tin
draining the ulcer was injected The night is
ure was taken six months later Tote the dis
appear ince of the diluted seins the herline, of
the ulcer and the return of shin colar

·34
Venous Diseases
Case 17 Chronic Venous Insufficiency, Varicose Veins, Ulceration
be
Note venous plexus ulceration pigment?
tion and devitalized shin
Two month follow up
Mr O II (The New York Hospital
#788253) is a 60 year old butcher For some
10 years he has lind varicose veins probably
? complication of standig still for many liours
erch day in his shop
Five
years ago ligations of the long and
short saphenous systems improved his legs
temporarily He did not weir elastic stochings
Pigmentition plexus formation stasis derma
titis and finally punful ulceration developed
He was hospitalized and shin grafted The
ulcer recurred His surgeon referred him to us
and the left photograph was taken Note the
venous plexus ulceration pigmentation and
devitalized skin
A communicating vein was paipated
slightly above the ulcer It was sclerosed
using the empty vein technic He was fitted
with a pressure gradient elastic stocking
Healing wis rapid is shown in the right
photograph He returned to his work is a
butcher und lus remained well

·35 Case 18 Clironic Venous Insufficiency Case 18 Chronic I enous Insufficiency Varicose Veins, Ulceration Ulceration and dentalized skin Close up of ulcerated area Six month follou up Mr WC (The New York Hospital veins A slight bump of his ankle led to ulccr #773617) is a 56 year old metal worker Ten formation years ago he suffered fractured tibias During The upper left figure shows the ulceration has enforced immobilization in a plaster cast and devitalized skin The upper right figure is he developed thrombophlebitis This is a com a close up of the ulcerated are? Two defec mon complication of fractures tive veins suth retrograde flos led to the ulcer They were obliterated by the empty The phlebitis destroyed the deep venous sein technic He was fitted with a graded pres Vahics and left him with thronic venous in sure elastic stocking The loner higure taken sufficiency Pigmentation and devitalization of sxx months later shows excellent healing and the skin soon followed together sath varicose return to health of the devitalized skin ·36 Venous Diseases 2 THROMBOPHLEBITIS Inflammation in or around a vein with clot → Neoplastic invasion of vein formation is known as thrombophlebitis 3 Venous compression-luth or without throm When intravascular thrombus form ition is bosis of thrombophlebitis due to due to venous stasis or to alterations in the (1) Gravid uterus blood which increase the clotting tendency (b) Neoplasin (c) Aneurysm ind is only followed secondarily by inflamma (d) Scur tissue tion it is frequently termed phlebothrombosis (e) Scalenus syndrome It is often difficult to classify a cuse as belong (f) Frictures and dislocations ing clearly to either group while in some ig) Increased intraabdominal pressure (as cites etc ) patients the process it the time of onset is of (h) Extrinsic pressure (tight gırdles circular one or the other type after several days in garters poorly made trusses etc) firmmation and thrombosis are usually co The wide variations in etiology and mech existent nnisms are clear in the above classification Classification and Etrology The classific? The underlying factors in any one case may be tion presented here is from the Nomenclature further clarified by study Triuma or damage of Diseases of the Blood and Lymph Vessels to a vein w all may initiate a thrombus forma prepared by ? committee of the New York tion especially when a substance to be injected Heart Association (1) is irritating in nature such as arsenichis escor bic acid glucose vreomycin and cert un of I Thrombophlebitis ind venous thrombosis (phlebothrombosis) the opaque media used for r ry visualization (1) Primary of the vascular tree In addition it is now (1) Thromboangntis obliterans established that cortisone ACTH and certain (2) Recurrent or migrating (without oral arsenical compounds should be used with arterial lesions) great caution in the presence of any condition (3) Essential which exhibits a thrombotic tendency It is (b) Secondary to (1) Mechanical injury (contusion lac recommended that crystalline trypsin not be ernation surgery) tised in clinical practice since it exerts ? (2) Muscular effort or strain thrombosing action prior to the anticoagulant (3) Chemical injury (sclerosing agents action The anti inflammatory action which is drugs solutions for diagnosis) (4) Inflamm tory or suppurative le clumed for it is inadequately documented at sions--infectious diseases present Stasis per se may be the inciting fac a Tuberculosis syphilis actinomy tor Increased tendency to clot formation in itself may lead to thrombosis as in cases of b Other bacteria (to be specified) pincreatic neoplasm (5) Infectious diseases Diagnosis The finding of i red tender (6) Sesere ischem (7) Chronic disease of vein wall (var hot punful cord in the course of 1 sein is the nes phlebosclerosis) (Later com pathognomonic sign Frequently however ? plications varicose or postphle deep vein is invoked without superficial signs bitic ulcers) In such cases reliance is placed on indirect (8) Blood dyscrasias (polycythema findings to make 1 dignosis These are de vera leukemia pemicious anemia) (9) Congestre heart failure pendent edem? and cyanosis of the affected limb the dilatation of collateral teins deep (10) Carcinoma COSIS ·37 Thrombophlebitis Treatment petroleum jelly or cold cream to present muscle tenderness pain on passne motion or maceration from the long exposure to mo stretching fever and constitutional sympturt toms Often cdemi and swelling mis he 4 Serie Blocks Roris it may be nece mashed and reserled onk hy accurate ml measuremerts (circumferesse) camping Stry to perform sympathetic nerve blocks toy release insosp ism It is consulta la mine to qual levels in opposite catremities he hazirdous to perform this procedure wink TREATMENT achile anticoagulint therapy is in progress The decision must therefore le mide arts 1 Elevation An uni oli ed extremits should be elevated approximately four aches ahore 5 Analgesia anil Treatment of Crampe the level of the heart This is especially indi Night crimps may frequentis be there is cited and may lie increased to eight inches in 02 gm of quinine sulfate at bedtime or » the presence of definite edu ma The purpose is 005 gm of bcuading? to facilitate draina,c of static hmph and 6 Antifungus Thierry Dermilophustosis venoits fluid from the extremity This measure of the toes and feet beeinst it is n portal of klds greatly to the patients comfort Elevation entrs fos microorganisms should be ninch is best accomplished by rusing the foot of thic Combited by the usual me ins (A Vinny loot bec six to eight inches on blocks The use of soaks 1/1000011 lutficlas ointment fall pillows Wone too frequently nsults in clera strength or wxlerkenc acid aintments) Our tron of the knce above the foot and therefore treatment should by avoide interferes with proper drainage distal to the 7 Constitutional Treatment Duhudration knee In the presence of occlusive arterial must byc nodd particularh since it increases discuse it is uniuse to elevate the extremity the tendency to thrombus formation Uniess In such a paradaxıcal situation the use of an there is some cuist of sodsum setention is oscillating bed will help to reduce the edem? renal or cardınc discrise cdcmr will not in safely Otherwise the extremity should be crease from a liberal Rud stake Lept in a horizontal position 8 Anticoagulant Therapy The use of antı 2 Rest Although it is important to keep coagulants requires well truined teams of the patient active as a preventive postopera ni orkers and hboratories prepared to provale tive measure in order to discourage the pro scrupulous service Unless the laboritons duction of clots and the development of technic for determination of the protlıromlin thrombophlebitis once thrombophlebitis hus time is properls standardized md can be been recognized the patient should be placed depended on at hed rest until the signs of active phlebitis use of coumarin or plienslın danedioni derniatures should not be at have subsided 3 Ileat Gentle warmtb is one of the best tempted When lome therapy is undertaken meuns of releasing venospasm and producing provision should be made for frequent datus analgesi Astrsiospasm is also a frequent mination of the prothrombin level by ruluille comphoitron of phlebitis A warm moist pack laluatory technicians les relaxation of both arternal and venous Barker and others (2) at the Mayo Clinic trees comparable to that produced by lumbar clearly demonstrated the greit value of de ganglionic block It may be muntamed over cumarol the prevention of pulmonin long periods and is a great deal simpler The umbolt in treating cases of phile bites Zilliacus picks ve at first applied for 20 out of cach 24 (3) and others huic shaun 7 similar Ix. neficial hours decreasing the time as the condition effect szt! heparin These results omic boxen improves It is wise to cover the skin with reproduced in many chinies throughout the world ·36 Venous Diseases 2 THROMBOPHLEBITIS Inflammation in or around a vein with clot formation is known as thrombophlebitis When intravascular thrombus formation is due to venous stasis or to alterations in the blood which incrense the clotting tendency and is only followed secondarily by inflamma tion it is frequently termed phlebothrombosis It is often difficult to classify a case is belong ing clearly to either group While in some patients the process at the time of onset is of one or the other type after several days in flammation and thrombosis are usually co existent Classification and Etiology The classifica tion presented here is from the Nomenclature of Diseases of the Blood and Lymph Vessels prepared by 1 committee of the New York Heart Association (1) 1 Thrombophlebitis and venous thrombosis (phlebothrombosis) (a) Primary (1) Thromboangutis obliterans (2) Recurrent or migrating (without arterial lesions) (3) Essential (b) Secondıry to (1) Mechanical injury (contusion lac eration surgery) (2) Muscular effort or strain (3) Chemical injury (sclerosing agents drugs solutions for diagnosis) (4) Inflammatory or suppurative le sions-infectious diseases a Tuberculosis syphilis actinomy b Other bacteria (to be specified) (5) Infectious diseases (6) Severe ischemia (7) Chronic disease of sein wall (var ices phlebosclerosis) (Later com plications varicose or postphle bitic ulcers) (8) Blood dyscrasias (polycy themia vera leukemia pernicious anemia) (9) Congestive heart failure (10) Carcinoma 2 Neoplastic invasion of vein 3 Venous compression with or without throm bosis of thrombophlebitis due to (a) Gravid uterus (b) Neoplasm (c) Aneurysm (d) Scar tissue (e) Scalenus syndrome (f) Fructures and dislocations (g) Increased intrabdominal pressure (as cites etc ) (h) Extrinsic pressure (tight girdles circular garters poorly made trusses etc ) The wide variations in etiology and mech anisms ire clear in the above classification The underlying factors in any one case may be further clarified by study Truumi or damage to i vein wall muy initiate 1 thrombus forma tion especially when i substance to be injected is irritating in nature such as arsenicals ascor bic acid glucose pureomycin and certain of the opaque medra used for ry visualization of the vascular tree In addition it is now established that cortisone ACTH and certain oral arsenical compounds should be used with great crution in the presence of any condition which exhibits ? thrombotic tendency It is recommended that crystalline trypsin not be used in clinical practice since it cxerts? thrombosing action prior to the anticoagulant action The anti inflammatory action which is clumed for it is inadequately documented at present Stasis per se may be the inciting foc tor Increased tendency to clot formation in itself may lead to thrombosis as in cases of pancreatic neoplasm Diagnosis The finding of 1 red tender hot punful cord in the course of a vein is the pathognomonic sign Frequently however a deep rein is involved without superficial signs In such cases reliance is placed on indirect findings to make a dignosis These are de pendent edemı and cyanosis of the affected limb the dilatation of collateral veins deep COSIS

·39
Thrombophlebitis After Care
with the foot of the bed elevated on blocks
six to eight inches high
2 Compression When up and about he
should wear a firm well fitted elastic stocking
extending from just above the toes to one inch
below the knee These are provided for him
when he begins ambulation
3 Hydrotherapy Swimming or walking in
deep water should be encouraged
In other words even effort should be
mide to present the edema from becoming
static or fired until the compensating venous
circulation is able to develop

·38 The experimental work of Burt and his col lergues (4) indicates that clots are absorbed more quickly if the patient reccies anti congulint therapy TECHNIC OI ADMINISTRATION OF ANTICOAGULANTS 1 The prothrombin time is determined by the Quick or Link Shapiro technic before the first dose is guen Normal readings are 12 to 13 seconds by the Quick method and 13 to 17 seconds by the Link Shapiro method 2 If the prothrombin time is normal or lower 300 mg of dicumarol is administered orally in one dose If embol have occurred hepırın may be started immediately and con tinued until the dicunrrol effect is minifested 3 Each day the prothrombin time is de termined and reported to the physiciın in charge of the patient before the dicumarol dosage for that day is decided on 4 The second day 150 to 200 mg of di cumırol is given and thereafter it is given in doses averaging 25 to 100 mg duly (depend ing on the patients sensitivity to the drug) An effort should be made to Leep the pro thrombin time one and one half to twice the normal time 5 If the prothrombin time reaches 35 seconds dicum rol is discontinued until the prothrombin time drops below 30 seconds after which it is given iguin cautiously in daily doses of 25 to 100 mg (These prothrom bin time values are based on studies using the Link Shapiro method ) The time may in crease for several days after dicumarol is dis continued and then return toward normal 6 If the prothrombin time reaches 60 or 70 seconds hemorrhagic manifestations may occur and one must be alert to this possibility At a level of 60 to 65 seconds 10 mg of vita min hy should be given orilly Minor hemor rhagic manifestations such as purpuric spots minor oozing from the gums and some red blood cells in the urine ure occasionally seen Venous Diseases They are considered to be signals for alert but not necessarily in indication to discontinue the anticoagulant therapy More sccre hem orrhagic manifestations cin sunlly be checked by giving vitamin A, orilly The ols jective is to keep the prothrombin level be tween 25 and 35 seconds especially during the first two or three wechs The dosage is then tapered off slowly over a period of from one to two weeks permitting a gradual retum of the prothrombin time to normil Dicum in hus been continued in most of our cases until the patient his resumed his accustomed ac tivities This is usually from 15 to 30 days after the last episode of thrombosis or embolism When embolic phenomena love already occurred it is usunllndvisable to give heparın during the first 24 to 48 hours until the effect of the first dose of documvol is established The subcutaneous injection of concentrated heparin (10 000 u per ml ) is very satisfactory With an average dose of 15 000 u ndequite anticoagulant activity is obtuned for 8 to 12 hours Sublingual administration of hepırı has fuled completely to produce iny change in the clotting time in tests run in our laboratory AFTER CARE Vari During the acute pliase of thrombophile bitis the valves of the insolved veins often be come enmeshed in the inflammatory action and are deformed or destroyed Months or years later the absence of these valves shows itself in the involved leg by the signs of chronic venous insufficiency They are cose vein formation congestion of dependent tissues especially at the ankle hemosidern deposit plexus formation stasis dermatitis and ulceration of the skin To present this unfortunate chain of cients the following instructions we given to the patient when he leaves the liospital or is sumes his normal mode of living 1 Elevation The patient should sleep ·Case 19 Thrombophlebitis On examination the long saphenous vem was found to be thrombosed from mid thigh to calf Large clots filled the dilated varices Some measured as much as one inch in diameter The foot and ankle were swollen with 3+ putting edema The calf at its mari mum circumference measured two inches greater than the other calf On dependency? Jeep Yanosis developed When standing col lateral seins became prominent over the hip Weight bearing produced pain in the foot and leg Passive flexion of the foot elicited call pain She was placed at bed rest The foot of the bed wis elevated on six inch blocks Hot moist racks were applied Anticoagulants were administered 15000 u of hepard was ghen subcutaneously every 12 hours The con centrated form was used (10 000 u per ml) On the thurd day dicumarol was started Therapeutic levels of prothrombin time were reached on the fifth day Heparin was discon tinued and dicumarol was maintained at a daily dose that kept the prothrombin time be tween 25 and 35 seconds Pam and tenderness subsided rapidly but the hard clots persisted for many weeks On the tenth day her temperature returned to normal She was ambulated A well fitted elas tic stocking was made It extended from the toes to one inch belou the knee On the tuen treth day she wis discharged from the los pital She was instructed to 1 walk about with the stocking on , sleep with the foot of the bed elevated 3 swim or walk in deep uiter as often as possible of clevate the foct on a footstool when sitting 5 ayod tight garments and sitting for long periods of time as in 1 trun or plane trp Dicumarol was continued for an additional sir wechs Ench noch lier prothrombin time was checked and she was cautioned to expect rches ind puns in luce legs from time to time especially when there was 1 sudden fall in birometric pressure After six wells the dose of drum rol was gradually decreased then stopped in two wechs She returned to her position as 1 chirh One year later her leg showed the varicose Teins as before but no additional signs of enous insufficiency hnd developed is hier elastic stocking protected lier She was told that her venous insufficiene could be um proved only by surgery but that if she fol lowed the regimen se outlined she miglit escape further difficult ller clastic stocking hird to be replaced esery tluree months The illustration shows linge 107 of phle bitis in the intemal saphenous sein

·Venous Diseases
Case 19 Acute Superficial Thrombophlebitis in Varicose Veins
with Extension to Deep Veins
This patient is 1 stout middle aged white
koman Varicose veins are prevent in both
sides of her family she inherited weth venous
kes After years of standing these inlics
ruptured one after another util the entire
venous system from heart to inhle u as desord
of this protection Under this increzsed hend
of pressure the superficial veins become
widely dilated and varicose
One day slic took a long automobile trip
She wore a girdle In the sitting position this
girdle bunched up in the groin ind acted as a
tourniquet to impede blood flow The sing
nint blood clotted in the veins
The following du she noticed red tender
hot cords along her inner tlugh They quickli
extended down to the knee ind calf The fol
los
ing da the entire leg * as flo}len dhe in
blockage of the deep veins She duscloped 7
feier

·43 Pulmonary Embolism and Infarction Symptoms 3 PULMONARY EVBOLISM AND INFARCTION berg (5) uds in understanding this phe Pulmonary embolism is very frequently nomenon lle subjected a series of dogs to overlooked or misdagnosed in clinical prac tice Surgeons are apt to confuse it with post artificiul pulmonary embolization No roent operatne atelect isis or pneumonia (Case 23) genograpluc changes in the lungs were ob until active thrombophlebitis becomes exi sened in uncomplicated pulmonin mlınlısm and no infarction occurred as long as the dent General practitioners are prone to con fuse it with vrus pneumonia until the patient curculition through the bronchial artery " is intact calls attention to the pain in his leg We have treated tuo physicians each of whom had The recent work of knusel (17) and luis been so diagnosed by their confreres One had group suggests that mechanical blockie is four attacks" before the phlebitis in his sa tht cause of dt ath 1 pulmonary emlxılısın phenous sein wis given its proper signifi rather than rek visospasm Infuction usu cance Patients with rheumatic heart disease ally extends to the surface of the lungs The have been treated for multiple episodes of untated plata seasts by an outpouring of pneumonia over a penod of years until em furd Pleural effusion is thus a frequent find bolization finally has been correctly diagnosed ing Blool exudes through damaged capillary as in the instance of Case 24 On care ful study walls into alveolar spices Therefore hemop prrents diagnosed as having pulmonary dis tysis is also a common finding case have occasionally proved to have bad a Symptoms Pain is often the first and most myocardial infarction with pulmonary em compelling symptom Two types of pain are bolism from a mural thrombus encountered 1 that produced by Tonetion of Farmer and Smithwick (1) have reported the pleura overlying the infection and 2 on 7313 consecutive surgical admissions In severe anterior chest pain often indistinguish 95 of these pulmonary infarction was recog able from that of myonora It sometimes nized in 25 pulmonary infarction was the first produces "splintings and difficulty in breath indication that phlebitis was present ing Some workers buhoc that this pain is The terms pulmonary embolism and pul the result of an actual diminution in the coro monary infarction are not synonymous A nary fox secondary to the profound desturls pulmonary embolism means that 2 foreign ances in the local hemodynamics (234) body most commonly a portion of a throm Others hold that this pain is located in the bus has lodged in a branch of a pulmonary pulmonary artery itself This question has not artery with or without changes in the lung been settled as yet tissues supplied by that branch If there is a Dyspnea is common It is due to the splint profound change in the lung tissue which ing caused by pam rather than progresses to necrosis the term infarction is the dysfunc tion of the rather small amount of lung tissue used Embolt in the absence of infarction do usually involved with a large embolus death not usually produce detectable r ray changes unless opaque visualization studies are per may ensue instantly or within a very few minutes formed If the disturbed area is near the lung surface however changes in physical signs Cough with hemoptysis of slight or $ill be noted especially the finding of sales marked degree is a most important corrobori or a pleural friction rub The work of hyel! tive sign Without at a diagnosis is often diffi cult to establish We have seen patients how ·42 Venous Diseases Case 20 Chronic Recurrent Low Grade Phlebitis wb Chronic phlebitis Six month follow up Miss G is a 55 year old clerk About 20 years ago she developed a superficial phlebitis in her left leg following slight trauma It had recurred several times Each recurrence re quired bed rest for as long as two months The long saphenous vein was ligated Varices were interrupted and removed on several occasions The episodes of phlebitis recurred The left figure shows her on her admission to The New York Hospital (#755214) Hard indurated tender lumps were present from the ankle to the mid calf Large superficial veins were found draining into this area The blood flow was reversed in these veins They were sclerosed using the empty vein technic The foot of the bed was elevated Heparin was given for two weeks A well fitted elastic stocking was made She returned to work greatly improved but with some induration still present She continued to treat it at home applying hot moist packs to the lesion for one hour cach night It took six months to clear the remain ing inflammatory areas She must continue to wear her elastic stocking the rest of her life and follow the regimen outlined for Case 19 Her prognosis for continued activity is excel lent In the left figure note the brawny indur? tion above the ankle This is the site of 2 low grade chronic phlebitis The dark areis above this are sites of hemosiderin deposits ind dilated varices Stasis eczem? and ulceration are present The right figure taken six months later shows the return of the tissues to health ·Pulmonary Embolism and infarction Symptoms 43 3 PULMONARI EMBOLISM AND INFARCTION Pulmonary embolism is very frequently berg (5) vs in inderst inding thus phic overlooked or mısdır,nosed in clinical pric nomenon lle subjected a series of dogs to artificial pulmon iri imhohzation lo roent tice Surgeons are apt to confuse it with post operabie atelectasis or pneumonia (Case 23) genosrapluc changes in the lungs were ob until actre th ombophlebitis becomes evi son(d in uncomplicated pulmonars embolam dent General practitioners are prone to con and no infarction occurred as long 15 the fuse it with virus pneumonit until the patient circulation through the bronch) ister 15 intact calis attention to the pain in his leg le huic treated to physicians eich of whom hud Tie riant work of knuse (17) mil has been so diagnosed by their confreres One had group suggests that mechanical block 140 is four a tacks before the phlebitis in his sa the cause of death in pulmon in embolism phe ous sera was gnen its proper signifi rather than refler wasospasm Infirctinn usu) cance Patients with rheumatic heart disease ally extends to the surface of the Jung The have been treated for multiple episodes of urtated pleura reacts l» in outpouring of pneumonia per a period of years until em fuid Pleur ui effusion is thus a frequent find bolization fipally has been correcth diagnosed ang Blood erudes through damı,ed capillary as in the instance of Case 24 On careful study walls into alıcolar spaces Therefore bemop ratents diagnosed as having pulmonary dis tysis is also a common finding ease have occasionally proved to have had a Symptoms Pam is often the first and most myocardial infarction with pulmonary em compelling symptom Two types of pun arc bolism from a mural thrombus encountered 1 that produced by reaction of Farmer and Smithwick (1) have reported the pleura overlying the infarction and 2 on 7343 copsecutic surgical admissions in severe anterior chest pain often indistinguish Go of these pulmonary infarction was recor able from that of my inoxin It sometimes rized in 5 pulmonary infarction was the first produces "splinting and difficulty in breath indication that phleb tas was present ing Some workers believe that this pain is The terms pulmonary embolism and pul the result of an actual diminution in the coro monaty ufarction are not synonymous A nary flow secondary to the profound disturb fulmonary embolism means that a foreign ances in the local hemodynamics (234) body most commonly a portion of a throm Others hold that this pun is located in the bya has lodged in a branch of a pulmonary pulmonary artery stscl Tlus question has not artery with or without changes in the lung been settled as set dissues supplied by that branch If there is a Dyspnea is common It is due to the splint profound change in the lung tissue which ing caused by pun rather than by the lysfunc progresses to necrosis the term infarction is tion of the rather small amount of lung tissue used Embols in the absence of infarction do wually in oked With a large cmbolus death not usually produce detectable x ray changes unless opaque visualization studies are per ma; ensue instantly or within a very few formed if the disturbed area ss near the lung surface however changes in physical signs Coul with hemoptysis of slight or will be noted especially the finding of rales marked degree is a most important corrobora O a pleural friction rub The work of Kjell tive sign Without it a diagnosis is often diffi cult to establish We have seen patients how minutes ·ray The on 44 ever with convincing evidence of pulmonary infuction without hemoptysis and even in the absence of positive x ry findings The cmotional reaction may be one of pinic and fear of disaster This depends the patients personality but the panic reac tion is sufficiently common to warrant com ment Signs Feuer will depend on the degree of infarction or secondary pncumonitis and the presence or absence of phlebitis nt the site of origin Some fever is usually present and it may be marked Heart Rate and Rhythm Tichy cardıı is present in proportion to the fever Arrhyth mins are often present and are responsible for many emboli especially in rheumatic heurt disease Any prtient who is fibrillnting is a candidate for pulmonary emboli We have seen a patient in normal rhythm have in episode of paroxysmal fibrillation discharge in embolus and revert to normal rhythm in a period of several hours Emboli may be dis charged from hearts in normal rhythm especi ally if there is evidence of valvular damage It is our impression that it is the recently formed thrombus or recently propagated new clot superimposed upon old clot in a heart or vein that tends to break off and embolize Signs of consolidation dullness to percus sion bronchial breathing rules and a pleural friction rub may be present of the infarct is large enough Over areas of pleural effusion dımınıshed breath and voice sounds will be heard As the effusion increases flatness de velops Careful examination should at least show rules somewhere in the chest to support the diagnosis It is however all advised to ask the patient to breathe deeply for this purpose This creates i negatis e pressure and may suck another embolus loose from the venous system Fındıngs Laboratory Leukocytosis with an increase in polymorphonucleur leukocytes is usually present depending on the presence or absence of phlebitis and pneumonitis The Venous Diseases sedimentation rate increases rapidly during the first week X presence of 1 shadow in the lung fields will be found only if some degree of infarction has occurred The shape size and density of the shadow depend on the angle which the infarct makes to the direction of the xrays Thus shndous vary from small hazy mottled areas to large dense segments If seen in several different vers during the period of observation the diagnosis is further substantrated The classic pic shaped area While sometimes seen is not found in the majority of cases Some degree of pleural effusion is usually seen in the v ray films some time during the course of the illness Electrocardiographic A large pulmonary embolus by blocking ? generous percentage of pulmonary arterial flow produces an in crease in pulmonary artery pressure This in turn is reflected in the heart by dilution of the right ventricle and what is termed "right herrt struin" The electrical changes are a shift of the us to the right with clockwise rotation This gives the following changes in the leads I Deep S depressed ST III- elevated ST nVR-R elevated ST aVL--depressed ST inserted T aVF-elevated ST V and V-R prominent elev uted St VAT pro longed V V V-ST depressed S mrrhed in V V Variations from this pattern depend on the size and location of the embolus Complications Cor pulmonale Acute dılı tion of the nght ventricle ind pulmonary conus may follow massive pulmonary emboli These changes may produce signs which can be recognized on physical crimination Ne current pulmonary emboli may produce chronic cor pulmonale Distention and in creased pulsations of the veins of the neck are common signs Increase in pulsation may also be noted in the second and third inter ·Or 15 Pulmonary Embolism and Infarchion Prevention and Treatment sulted in the initiation of prophylactıc meis spaces to the left of the stemum The second ures For example charts of patients who died pulmonary sound may be heard Over the area fram pulmonin embolism huc containe of increased pulsation Gallop rhythm heard notes such as patient compluns of pun in best to the left of the stemum may be pres left calf" or "pain in the right groin ent "sudden breathlessness or a "shup pun in Shock “Peripheral circulatory collapse the right chest" Vany other simples could may be present and requirc emergency meas be cited Because these inınal signals were ures While we recognize that shock is a sariable mamfestation most patients we have of short duration disappearing suithin a fex encountered in shock from pulmonary em days or csen hours their sinister significance bolization display cold moist pile hands was not recognized and stops were not taken moist face cyanosis weak feeble raped pulse to prevent further development of throm and hypotension boembolic complications As Bames pointed Differential Diagnosis Space does not per out 15 years 750 little could then be done mit discussion of all conditions which must be except wishful ilunkat if the pulmonary considered in a differential diagnosis The embolu were arising from the heart If the condition will be recognized more often if the Here arising from the scins of the legs lig? possibility of pulmonary embolus is kept in tion proximal to the site of a recognized mind All patients with cardiac arrhythmias thrombophlebitis appeared logical and sus rheumatic heurt disease recent myocardial the favored method of attack Experience lias infarcts recent surgery or fractures preg demonstrated however that I ligation does nancy policvthemia and phlebitis are apt to not prevent the actue thrombophilelutic proc. have pulmonary embolt ess from continuing ? ombols may and frequently do continue to arise froin veins PREVENTIOV AVD TREATMENT other than those ligated 3 fatal emboh mu in a sense pulmonary embolism may be arise from thrombi which have forncd im likened to lightning It strikes most often with mediately proximal to the site of ligation even great suddenness and if the patient sursies though this may be as high as the inferor the initial shock he has a good chance of sur vena cava 4 the late effects of ligation of the viving that particular embolus It is the emboli femoral or hac veins or the inferior vena cav? yet to be delivered that are most to be are often undesirable with serious culence of fcared indeed many large fatal pulmonary venous insufficiency associated with am emboli are preceded by small ones As Bar edema and ulceration Therefore ligation was ker (6) pointed out of all fatal pulmonary em found not to be a preventive measure of boli preceded by minor emboli could be pre choice except when it was desirable to elimi vented the death rate would be striksngly Date vancose veins a common site for recur reduced Autopsy statistics at The Jew York rent thrombophlebitis with sccondary emboli Hospital showed a rate of 10 per cent pul Erb and Schumann (7) reported their er monary embolism in the years before antico perience in 100 cases of fracture of the femur agulants were used à condition very frequently complcated by For this particular syndrome the best treatment is definitely presention A review pulmonary embolism Fifty patients were of a large number of case histories has shown subjected to bilateral femoral vein ligation that a greater awareness or a more careful and 50 were used as contrals The mortality study on the part of the physician would have rate was not lowered in the surgical group made him alert to signs which might have re indeed the legation stself was frequently fol lowed by thrombosis in the site proximal to ·46 the ligature Pulmonary embolism was in creased That surgical interruption of veins is not a treatment for phlebitis is well illustrated by 7 patient of ours While in the umy he had 1 sudden pulmonary embolus Erimination disclosed phlebitis in his left leg A left super ficial femoral vein ligation was performed During the convalescence from this opemtion 1 second pulmonary embolus occurred E amination disclosed phlebitis in his right leg This time in an effort to trap all possible emboli his inferior veni cu wis ligated Subsequently phlebitis developed in his arms and thereafter he had multiple pulmonary embol Since his physician did not wish to tie off the superior veni cavn he was referred to us for long term anticoagulant therapy There have been no further emboli during a period of eight yeurs The advent of anticoagulant drugs per mitted a new approach to the problem which is actually bused on the fact that under cer tain conditions the blood clots too easily The mechanism for this easy clotting is not under stood Exhaustive studies of the clotting fac tors frequently ful to clarify the picture Pieces of the original clot brezh off and travel to the lungs If the original clot could be pre vented from forming no such problem would ever arise If such a clot once formed could be contuned 2s 1 small process and allowed to scal itself off instead of propagating a tail which could break loose the nsk would be markedly lessened If emboli once delivered could be prevented from propagating and blocking off more branches of the pulmonary arterial tree the risk to life would decrease All of these accomplishments are theoretically possible with the perfect anticoagulant used correctly under favorable conditions All of them have been achieved in varying degree and often with staking success with the presently available anticoagulants Many stud les have demonstrated a striking reduction in mortality and morbidity when anticoagulants Venous Diseases hwe been used either prophylactically pror to the first pulmonary embolus or even after the first embolus in the prevention of sub sequent ones A summary of the results of scieril large series of patients with postoperative throm bophlebitis shows the following once throm bophlebitis has been recognized in the absence of anticoagulant therapy the risk of pulmonary embolism ranges from 4 to 60 per cent of those patients who have had one embolus the risk of death from a subsequent embolus is approximately 20 per cent In contrast patients with postoperative throm bophlebitis who receive adequate anticoagu lant therapy suffer from pulmonary emboli in less than 5 per cent of cises and the mortalıts rates are under 05 per cent (8) These are indeed striking figures They have been du plicated with hepının heparin and the cou marın derivatives combined and the coumarin derivatives alone In obstetric cases (9) the incidence of pulmonary embolism follow ing untreated thrombophlebitis has been reported as ranging from 15 to 35 per cent with a mortality rate of 3 to 5 per cent This jos mortality may be associated with the finding of the Committee on Anticoagulants (10) that while the younger patients had nearly as many emboli as older patients the mortality rate was much lower probably because of their ability to stand the reaction or shock In addition it is probable that more of the pulmonary emboli in obstetric patients arise from pelvic veins of smaller caliber and hence are less likely to be fatal While it appears that once a thrombus or 7 pulmonary embolus has been recognized anticoagulant therapy is the most important form of therapy certain other measures should be borne in mind As mentioned previously when carrying on a physical examination of the chest the physician should scrupulously woid having the patient inhale deeply or cough since such maneuvers increase the negative venous pros ·litung bed Pulmonary Embolism and Infarction Presention and Treatment walking in all patients we prefer the osci sure thus developing a most favorable condi tion to suck loose the tail of a clot which may 2 Deep firsatlung many times then travel into the lungs Diallis haic ac should be immediately discontinued on am Curred directly following such mantulers sign of thrombosis or embolism The patient must be s imed agamst straming 3 Is the treatment of phlebitis se ele at stool thus producing a Valsalva experiment Vate the foot of the bed to speed up the following which the hemodyname pressures flow of blood through the senous channels of are markedly disturbed in one senes 20 per cent of the deaths from pulmonary embolism the legs and pelvis and to present stasis four ere reported as occurring at stool The phys many fears it has been our practice to do this Iuan must provide laxatives to prevent this as a prophylactic measure follou ing surgen hverven er the surgeon feels the operative pro situation As discussed elsewhere the acute renction cedure permits it and also provided that the of pulmonary embolism has been thought to artenal supply to the limbs as adequate (15) le due in part to spasm of the artery This led Mone of these surgical patients has had a post to the use of antispasmodic substances in nperatne pulmonary embolus Torpin (12) cluding papaverwe aminophylline atropine kas repartedl similar results namely free ind opium derivatives seporately or in com dom from pulmonary embol following 1,300 bination as for example Spaşmalgın Favor gynecologic operations using this simple able results have been reported following their prophı lactic measure The usc of an oscillat use but large well controlled senes are not ing bed for chronically ill or postoperate available Nevertheless it seems advisable to patients has much to recommend at the ru use these or other relaxing agents to alla; the peated filling and emptying of the sells extreme tension so commonly present in these should aid in prevention of phlebitis patients 4 Flastic stockings are used in the preven Twenty years ago serious attempts were tion of pulmonary embolism Wilkins and mide to develop operative procedures for re Stanton (16) he recently reported that in 1 moral of pulmonary embol but they were series of over 5000 routine hospital admis very hazardous and with the advent of antı slons pulmonary emboll were significants coagulant therapy they have been abandoned reduced by the continuous wearing of light The use of oxygen is indicated in the elastic hose presence of dyspnea or cyanosis In secent years ef 5 Prophylactic ligation of the seins post forts have been made to reduce the cheace operately as much less popular than it was of the postoperative thromboembolism prior years ago Some workers have even re to its original development The most popular ported more embolı after kgation than in a methods have secluded the following control senes We do not favor this procedure 1 Early ambulanon within 24 hours of 6 We should not recommend anticoagu the operation or delivery is still a matter of lant therapy on a purely prophylactic basis in controversy but we incline toward the evi all patients or after all operations but certain dence in favor of it Active proponents of this situations probably justify its use according method have pointed out that merely sitting to farge senes seported by Barker Brambet in a chair as commonly practiced is not an and others and our oun etperience These bulation and indeed greater stasis may occur include 1 major pek ze surgery hernur with the legs in dependency for long periods thaphy 3 major abdominal surgery especially than if they are actively moved in bed or by in the presence of a history of former throm boembolic conditions 4 surgery on older ·48 persons 5 surgery in the presence of auricular fibrillation, coronary artery disease or passive congestion, 6 the presence of marked varicose veins or venous insufficiency 7 after delivery when the mother has had previous thrombo phlebitis or pulmonary embolism ind 8 in all patients who hne previously demonstrated a tendency toward thrombosis or embolism Long Term Anticoagulant Therapy The treatment of pulmonury embolism should not be limited to 1 consideration of the acute episode first cncountered This mu be i sin gle experience secondary to thrombosis which becomes organized and causes no further Venous Diseases trouble and treatment of three to four weels duration may be sufficient On the other hand the patient may continue to have repeated cmboll from chronic recurrent thromboble bitis or from 1 heurt in auricular fibrillation We lze patients who have had as many as twenty emboh from such sources It then be comes necessary to employ long term anti corgulant therapy The results of such therapy rre encouraging and hue been reported by us (13 14) We have now maintained more thin 100 patients for from 1 to 18 years on anticoagulants ·19 Case 21 Recurrent Idiopathic Phlebitis Case 21 Recurrent Idiopathic Phlebitis (Long Term Anticongulant Therapy) Mrs B has a family history of intravas cular clotting Her father died of a pulmonary embolus ller mother had had recurrent phle bitis and also died of a pulmonan embolus At the age of 42 she developed a super ficial phlebitis which extended to the deep vers A pulmonary embolus followed This was before the era of anticoagulants so both femoral veins were ligated to prevent further emboli During the next several years she developed repeated attacks of phlebitis in the legs and arms Each attack resulted in mand em Dicumarol therapy was started and con tinued successfully for eight years Attempts have since been made to take her off treat ment but as the prothrombin time sinks to a normal range fresh phlebitic areas appear There hue been no ill effects from her long term anticoagulant therapy nor lins thert been any serious bleeding At one time she commenced to have increased menstrual bleeding This is unusual with a normal uterus and in properly administered anticoagulant therapy Papanicolaou smears were positive hysterectomy was performed and a small car cinoma was found The anticoagulant thcrary had led to its bleeding and earl disconery This patient has resumed her dicumarol treatment She has now been on this regimen nine years and the clotting tendency in her blood although not understood may neces sitate continuation indefinitely of intico igual ant therapy

·50
Venous Diseases
Casc 22 Carcinoma of Breast with Multiple Vascular Thrombı
Embolus occluding renni vein
Microscopic section of lung with cmbolus
This young woman with 1 rapidly growing
cırcinomı of the breast developed multiple
thrombi in her seins heart and arteries
The left figure shows the kidney and renal
Vessels Note the occlusion of the renal vein
by in antemortem clot
The right figure is i microscropic section
of lung Note the embolus present in the pul
mon rry artery

·51 Case 23 Pulmonary Emboli Case 23 Pulmonary Embalı Causing Right licart Failure B Vierascopic section of lung wuth embolus A lote large dilated right ventrcle and the embolus in pulmonan artery past 10 This 45 year old housewife was admit ted to the hospital on December 19 1955 be ca e di uspnea on trertion that had become progressively worse over the years HISTORY The patient was so active as a child that she was considered a tomboy When she was 10 years old tuberculous cervical lymph nodes were removed at another hos pital Sne made a good recovery with no ap parent a'ter effects At the ages of 25 and 27 she became pregnant and had no difficulty during the birth of her children No history of rheumatic fever or chorea was obtained In 1947 dyspnea on exertion gradually devel oped while she was living in Reno Nevada An x ray unit visited her neighborhood an 1973 and the patient had a chest xray taken She was told to visit her physician because the flny showed an abnormal chest finding She ignored this advice but when the dyspnea became worse and orthopnea became prom inent she did visit her doctor in June 1955 Chest pain heinoptysis and dependent edema had not occurred but she had garned 30 pounds in the past two years and weighed 165 pounds Both the physicins rays and the mobile unit film showed bilaterally en larged hilar shadous Bronchoscopy path bronchial washing studies showed no abnor malities A supraclaviculır node biopss was also done but the results are not as nilable Because of the progression of her symptoms she came East and entered The New York Ilospital on December 19 1955 The temperature pulse and respirations were normal The patient was a well ucvcl oped and slightly obese woman who did not appear in any distress Healed scars were pres ent on both sides of the neck and there was a more recently healed left supraclavicular ·52 scar The neck veins were not distended and there was no dependent edem. There was no clubbing of the fingers or toes A few scittered rals were heard at the bases of ench lung The heut was slightly enlarged to the right and left A muld heave vas felt over the region of the right ventricle and the P. wus palpable The pulmonic second sound wis accentuated and ringing A very funt systolic mumur was heard over the pulmonic area and i moderate high pitched diminuendo di istolic murmur was noted along the left sternal border at the second and third left intercostal spaces No other abnormalities were found on physical cramination The urine was normal and the hemoglobin wis 163 gm per cent red blood cell count 53 million hem itocrit 49 per cent and white blood cell count 8 400 with i nor mal differential The Mizzini test showed a doubtful positive reaction The blood crer nitrogen was 12 mg per cent and the CO, was 21 mm/L A chest film showed moderato cırdınc enlargement and abnormal promi nence of the pulmonarı urtery segment and right ventricle Some pulmonary congestion Was also found An angiocardiogram showed some dilation of the right atrium and right ventricle with muhed enlargement of the pul moniry irtery and its major branches This study showed no eudence of a right to left shunt Cardiac catheterizition was done but ? complete study was not possible because of the patients lack of cooperntion An elevated right ventricle pressure of 128/12 mm of Hg was found and the uterial oxyhemoglobin saturation 1415 853 per cent Simultaneous de termination of oxyhemoglobin saturation from the right brachul artery was 879 per cent and from the right femoral artery 877 per cent The pH of the blood was 74 plasma CO content was 20 ml/L and CO tension 32 mm Hg The clectrocardiogram showed in incomplete right bundle brinch block with right ventricular hypertrophı She was dig italized and on ſinun 4 1956 she left the Venous Diseases hospital 16 diys after entry and retumed to Netadi Dunng the subsequent 21 months the dyspnea and orthopne i became worse and the patient lost 55 pounds During this period she had been hospitalized eight times in the llest and wis treated with mercurials digitalis phlebotomies ind on one occasion sth anti congulants In July 1957 dependent edema and cyanosis became noticeable hemor rhoidectomy was done in August 1957 at a Nes nda hospital Because of her continued downhill course sht reentered The \eu lork Hospital September 29 1957 EXAMINATION The temperature was 37 C the pulse rate 100 respiration was 26 and the blood pressure 112/76 The patient was a thin cyanotic white womın who appetred chron acilly 11? The lips nuls tongue and buccal mucosa verc cyanotic Slight clubling of the fingers was found The neck seins were mod erately distended ind sacrul edema was prominent The thorar was slightly incre used in the interoposterior diameter and scattered fine rales at both buses were heard the heart was endurged 11 cm to the left of the mid sternal line in the fifth intercostal space A broad hene mas felt over the sternum The pulmonic second sound wis accentuated A blowing systolic murmur was heard at the zpet at the third interspice along the left sternal border a soft blowing systolic mur mur and a diminuendo diastolic murmur were described The abdomen was obese and the Inver vis felt down to the umbilicus but the spleen is not felt LABORATORY DATA Urine prottin 1+ kas noted and the sediment contained my clumps of white blood cells Blood the hemo globin was 165 gol per cent the red blood cell count 1 2 5 1 mullion the heinatocrit was 57 per cent the white blood cell count was 13 200 with 59 poly morphonuclears 11 bands 21 lymplocytes & monocy tes and I cosino plus the platelets were adequate The Vazzom test wis agun doubtfully positne The blood ·53 Case 23 Pulmonary Emboli urea nitrogen is 12 mg per ant bilirubin 07 m. per cent and uric acid 38 mg per cent carbon dioxide 24 mEq/L chlondes 98 mEq/L sodium 0 135 mEq/L and potassium 48 mEq/L. The prothrombin time was nor mal ray the chest showed an increase in cardiac size as compared with films of the first admission Enlargement of chambers and pulmonary artery was the same as that found in the past Electrocardiogram this showed 1 NSR with the incomplete right bundle branch block and ncht ventricular hypertrophy Stool gualac negatie Course Shortly after admission a phlebot omy of 350 ml was done She was treited with mercurial diuretics and digitalis was marntained on the fourteenth day she fell from her chur and struck the right side of her head but did not suffer any laceration or lose consciousness 4 skull v ray showed no frnc ture A second phlebotomy of 300 ml on the tuelfth day failed to lower the hematocrit usluich rem uned at 56 per cent The patient was 7 nursing problein refused to the food or medications and is very apprehensic Respirations became progressisch mori li lorecl incl she dice on the scicnte ( nith di AUTOPI I ADINCS The autops rud massise old and recent pulmon in thrombo emboli together with extensive sclerosis of the large and small arteries ind arteriolet night sentricle hypertroplı ind dilatation in con genital inom ulies were found in the licit The changes in the pulmonar vessels ap parentlı were the result of repeatedl okline recent embolization with subsequent throm bosis Figure A (p 51) shows the profounel lus pertrophy and dıl tation of the right sentricle enlargement of the pulmour arter and em boli present in the lumen Figure B (p 51) shows extensive thucken ing of the wall of pulmonary arterioles and 1 small arters ·52 scar The neck veins were not distended and there was no dependent edena There was no clubbing of the fingers or toes A few scattered rales were heard at the bases of each lung The heart was slightly enlarged to the right and left A mild heave was felt over the region of the rght ventricle and the P was palpable The pulmonic second sound is accentuated and ringing Very faint systolic murmur was heard over the pulmonic urca, ind a moderate high pitched diminuendo diastolic murmur was noted along the left sternal border at the second and third left intercostal spaces No other abnormalities were found on physical examination The urine was normal and the hemoglobin was 16 3 gm per cent red blood cell count 53 million hematocrit 49 per cent and white blood cell count 8 400 with a nor mal differential The Mazzını test showed a doubtful positive renction The blood urea nitrogen was 12 mg per cent and the CO. was 21 mM/L A chest film shou ed moderate cardınc enlargement and abnormal promi nence of the pulmon iry artery segment and right ventricle Some pulmonary congestion it is also found An angiocardiogram showed some dilation of the right atrium and right ventricle with murhed enlargement of the pul monary artery and its major branches This study showed no evidence of a right to left shunt Cardzic citheterization was done but a complete study was not possible because of the patients lack of cooperation An elevated right ventricle pressure of 128/12 mm of Hg was found and the arterial oryhemoglobin situration 1 is 85.3 per cent Simultaneous de termination of oxyhemoglobin saturation from the right brachial urter was 879 per cent and from the right femoral artery 877 per cent The pH of the blood is 74 plasma CO content was 20 mM/L and CO. tension 32 mm Hg The electrocardiogrım showed un incomplete right bundle branch block suith right sentricular hypertrophy She was dig italized and on January 4 1956 she left the Venous Diseases hospital 16 days after entry and returned to Nevidi During the subsequent 21 months the dyspnea and orthopnea became worse and the patient lost 55 pounds During this period she hrd been hospitalized eight times in the Il est and was treated with mercurials digitalis phlebotomies ind on one occasion with antı coagulants In July 1957 dependent edema ind cyanosis becime noticeable A hemor rhoidectomy was done in August 1957 at a Nevada hospital Because of her continued downhill course she reentered The Ncx lork Hospital September 29 1957 EXAMINATION The temperature was 37°C the pulse rate 100 respiration was 26 and the blood pressure 112/76 The patient was a thin cy anotic white woman who appeared chron ically all The lips, nuls tongue and buccal mucos? were cy anotic Slight clubbing of the fingers was found The neck seins were mod erately distended and sacral edema was prominent The thorau izs slightly increased in the interoposterior drumeter and scattered fine riles nt both buses were heard The heart was enlarged 11 cm to the left of the mid sternal line in the fifth intercostri space A broad here was felt over the stemum The pulmonic second sound « is accentunted A blowing systolic murmur was herrd nt the apes At the third interspace along the left sternal border 1 soft blowing systolic mur mur and a diminuendo diastolic murmur kere described The abdomen its obese and the Iuer was felt down to the umbilicus but the splen uw is not felt LABORATORY DATA Urine protein 1+ #as noted and the sediment contuned many clumps of white blood cells Blood the hemo globin 1 2$ 165 gm per cent the red blood cell count was 5 1 million the hematocrit was 57 per cent the wute blood ce}} count was 13 200 with 59 pols inorphonuclears 11 bands 21 lymphocytes 8 monocytes and i Losino pbil the platelets si ere adequate The Mizzim test u 15 again doubtfully positic The blood

·55
Case 25 Acute Pulmonary Infarction
Case 25 Acute Pulmonary Infarctior
1 50 year old man ("The New York Hos
pital #625583) had a cholecystectomy per
formed because of cholelithiasis On the
el_hth postoperative day he experienced sharp
pun in the right chest and rased blood
strealed sputum Deep phlebitis was found
in his right calf Anticoagulants were admin
istered promptly the leg was wrapped in
warm moist packs and elevated An unevent
ful recovery ensued
The illustration shows 7 portable chiest
film The right diaphragm is clcuated and
tented A pleural effusion is present There is
partial atelectasis of the right lower lobe

·51
Venous Diseases
Cisc 24 Multiple Small Pulmonary Emboli
A 57 yer old social service administrator
(The New York Hospital #530136) was first
seen in November 1948 During the previous
10 years she had hind eight illnesses that had
been dingnosed as lobur pneumonia On ad
mission she compluned of cough chest pun
and blood tinged sputum Erimination showed
typical signs of mitrul stenosis Vry of
the chest showed a shadow in the night lower
lung field Our dingnosis was pulmonary in
farction secondary to an embolus from rheu
matic heut discise Dicumurol therapy was
instituted and mutuned for two months
The patient lapsed from treatment Again she
hnd a sudden episode of chest pun cough
and blood streaked sputum

·57
Case 26 Pulmonary Emboli
Note generalized cardiac enlargement, bilateral pleural effusion and
increased density of the posterior basal segment of the night lower lobe at
site of pulmonary infarction

·56 Venous Diseases Case 20 Pulmonary Emboli A 51 ye ir old womin (The New York Hospital #570625) was first scen in June 1950 with i pulmon iry infrrction At the age of 14 she had had rheum itic frier and it eighteen she had been told she hd , heirt murmur Until lier present illness she had been en tirelt vcl She is i business elecutive and led a busy professional ind social litc The di prior to admission she lind developed severe pun in the right lower chest racing to the buch Eviminition disclosed signs of mitral stenosis and sortic stenosis There was i regular sinus rhythm interspersed with mm premature contractions Examination of the chest revealed dullness and diminished breith sounds at the right base posteriorly Ir of the chest as shown in the com panying dlustration This film shows general ized curdic enl ırgement biliter il pleural cffusion and in mercised densits in thie pos teror bis al segment of the night loner lobe which is consistent with the chnical findings of pulmon kry infarction Tlientiert rno 1 fcbril course for a veck She was gncn inticoagulants starting with hepirn ind shifting to dicum irol She is is digitalized and discharged on her fourteenth hospital dry Dicun rol was discontinued Tuo keeks later i second pulinon in infirction occurred She is readmitted to the hospital and ag un nen dicumarol The decision k is made to keep her on inticoagu Hunts perm inent! There hoe been no further emboli durng a period of six yeurs She reports (teri 14 dus for prothrombin deter minatrans She las hid seieril munor hem orrhagic manifest itions in the form of casi bruising ifter slight truumi but no major ones Her prothrombin time vises from 20 10 a lugh of 10 seconds Her nerge duh dose is 75 mg of dicum rol while under treit inent slc luis in de tuo business trips to C iformı? one to Puns ind Rome and many shorter trips Her blood tests have becn ar runged it rious paints as the play sicians in terested and trund in this work Her course His complicited four veirs ago by the devel opment of his perthyroidism Tlus 11 as success fully controlled with radio ictie nodme Thus patient represented 1 rise of rheu inatic heirt dise is not fibrill iting u uluch emboli from the right heart were delivered to the lungs ·59 Case 28 Pulmonary Embolism - Ratograph of pulmonary embolism lote localized arca of infiltration in night posterior costophrenic stilous with pleural reaction Examination showed splinting of the chest on anticoagulants in this case these were ad the right side Fler temperature rose to 39 C ministered as follows heparin (concentrated Examination of the legs was completely nor to 20 000 units per ml ) was gnen subcutane ma] The wute blood count was 7800 the ously every 12 hours an initial dose of 15000 differential count showed 69 mature polymor units wis gi en Blood congulation tests were phonuclear leukocytes 10 bands 12 lympho done duly The aim was to obtain a maximum cytes 8 monocytes and 1 eosinophil of three times the control coagulation time in Moist tales were present at the posterior a period of four hours after administration of huse on the right side ray of the chest the heparin Congulation time should return 1 shown in the accompanying figures) showed approximately to normal by the cuscitth lour a localized area of inbitration in the right pos The dose was varied each day rangmg from Crior costophrenic sulcus with a small a low of 10 000 units to a lugh of 15000 units amount of pleural reaction around it This was kept tip for a period of three vechs In the differential dugnosis the conditions Heparin alone was used in this patient be to be considered were a pneumonitis or a pul cause her husband a distmguished cardiol monin embolus The time of onset of pleur ogist had a personal preference for st and inic pam and the response to therapy made urged us to do so The fever slowly decrcased the dignosis of pulmonary embolus most during this period Chest symptoms persisted likely During any extensive surgery in the for about four days and then gradually sub pelus a great many small veins have to be sided Rales persisted for 12 days The abdo tied off These veins thrombose and thus tep men was tender but not more so than one resent potential sources of emboli Whether would expect from such a major surgical pro or not this is of clinical significance depends cedure The legs were at all times clinually on whether or not a clinically detectable em normal Because of the absence of involve bulus actually docs OLCUT ment in the legs it was not necessary for this The only therapy consisted of the use of patient to wear elastic stockings ·58 Venous Diseases Case 27 Pulmonary Embolus Note increased vascular markings ind bilateral pleural effusion Four ind i half seconds after intravenous injection of contrast medium A 44 year old white man hid had three previous episodes of myocardial infarction He also had had multiple pulmonary infarc tions The u ray of the chest (see the left fig ure) shows increased riscular murkugs in both lung fields and a biliteral pleurul of fusion The ingrocardiogr im (seu the right figure) by Dr Israel Steinberg mide four and a half seconds after the intravenous in jection of the contrast medium shows the pul mon iry conus pulmon ry artery and its major branches well outlined The brinches to thright louer lobe are irregulır and cut off and indie ate the point of lodgment of a pulmonuembolus The patient died several months later die topsy showed a lirge embolus in the righ lower pulmonary artery brunch multiple ole pulmon iry infarctions and multiple myocard nl infarctions He had not recewcd antico igul ints Cisc 28 l'ulmonary Embolism following Peluc Thrombophlebitis Mrs D P (The New Torh Hospital #711090) age 65 2 housewife has found to have 1 carcinoma of the endometrium Oper i tion was performed on Jinurry 28 1957 It consisted of total remos al of the uterus the tubes the ov tries the lymph nodes in the ulic and obturator areas Pathologic diagnosis was found to be adeno acanthomi with slight to moderate endometrial ini zsion and is culır lymphatic involvement The patient had a very calm postoperite course during the first 12 days llur tempera ture remuned between 37 and 38 C she ato Hell ind her mor uke 1115 good She 175 allowed up to the bathroom hid her meals sit ting up and walked about the room On Fib ruary 10 elcien dus ifter the operation she complamed of pun in the nght loser chest The pain was made worse bs luing on the right side Deep breathing is impossible

·Case 29 Pulmonary Embolus
61
One second film
Three second film
2
Six second film
Fourteen second film

·Venous Diseases Case 29 Pulmonary Embolus, Angiocardiogram W Front view showing en larged pulmonary conus This young woman with rheum itic heart disease iuricular fibrillation and mitru sten oss had a large pulmonary infarction The above photograph shows i front view of the chest The pulmonary conus is enlarged The right duphragm is prominent a pleural effusion is present and the right lower lobe is obscured by a mottled shadow The photograph on the facing page shows four viens mounted on one slide of the ingro cardiogram by Dr Isrnel Steinberg at intervals of 1 3 6 and 14 seconds after the intravenous injection of contrast medra The 1 second film shows the contrast med z outlining the superior ien? Cur and right atrium The 3 second flm shows the pulmonary conus and pulmonar artery brunches well outlined They are greitly diluted The 6 second film shous ar borization of the pulmonan branches with sharp termination of a large brunch to the right lower lobe probably at the site of the embolus The left iuricle is outlined and shows a double density possibh the site of 7 murul thrombus The 14 second film shows the left ventricle and aortoutlined Note hon small the aort 2 is compared to the delated pul monary arter ·Bibliography McDesit e Symons C and Wright IS Further experience with long term anti coagulant therapy Arch Int. Ved 9. 197 103) SUMMARY The importance and frequency of pulmon ary embolism have been discussed The diagnosis and tre itment have been presented Important strides have been made m the treat ment of this condition during the past 12 veats as a result of the advent of anticoagulant drugs While death and recurrent emboli may occur during such therapy the incidence of both has been strikingly reduced by the use of heparın cumarin and Indanedione deriv atives Greater anareness of the possibility of thrombosis and pulmonary embolism results in earlier dignosis and treatment and further reduction in mortality from these conditions BIBLIOGRAPHY VENOUS I\$UFICIENCY AND THROMBOPHLEBITIS 1 New York Heart Ass ciation Nomenclature and Cri erid 5th ed 1953 page 331 Barker N W (romer E Hurn M and laugh 1. V The use of dicumarol in the prevention of post operabye thrombosis and ernbolist with special relcrence to dosage and sale ad mustra tion Surgery 17 207 1945 3 Zilliacus it on the spefic treatment of throm bosts and pulmonary embolism with anticoag ulants with particular reference to the pos thrombotir Sequelae Acta med Scandinav Supp 171 1 1946 4 Burt C D Waght HP and Kubic M Clinical tests of a new coumarın substance Brt M ] 91.50 1949 5 Taylor A and Wright I S Intravenous trypsin Circulation 10 331 1934 6 Tagnon H J The nature of the mechanism of ste produred by the injection of bryps. ] Clin Investigation 24 1 1954 7 Cockett, 1 B Diagnosis and surgery of highpressure enous leaks in the leg Brit H'I 2 1399 1956 PULITOVARY EYBOLISV. ANT INFANCTION 1 Farmer D A and Smithuck R I Thrombor bolic disp.3se discussion of problem in surgical pahents with particular reference to fatalem bolus Angology 1 291 1990 Scherf D and Schonbrunner E Uhr llctzlx funde bei I ungenembollen Ztschr illon Vect 198 405 1932 3 and Schonbrunner C Uber den pulmocoronaren Reffer bei Lunge nemholien Mla Ichnschr 16 3-10 193 4 De Takats G Beck 11 C and Fenn Pulmonar embolism An experimental and clin ac study Surgery 6 339 1939 5 A jellberg S R and Ousan S E Roentgenological studies of experimental pulmonary embolism without complicating infarction in dog Acid radiol 33 507 1950 8 Basher N w Anticorgulant therapy in peripheral vascular disease Circulation 4 613 1951 7 Frb W Hand Schuinn ) An appraisal of by lateral superficul femoral vein bcation » fyre enting pulmonary embolism Application of the procedure in 100 controlled cases of fracture of the femoral neck Surgery 29 819 1951 8 Barties AR Pulmonary embolism JAVA 109 1347 1947 9 Brambel CEHunter RE and Fitzpatnck V DPP Prophylactic use of introagulants in puerperal period (dicumasol hepiin and Link compound 63) Bud School Ved Unuy Mary land 35 91 1950 10 Inght I s Marple CD and Bech DF Anticoagulant therapy of coronary thrombosis with myocassiial infarction JAV 138 1074 1948 11 Vascular Diseases in Clinical Practice 2nd ed Chicago The Year Book Publishers Inc 1952 p 439 12 Turpm R Pulmonary embolus postoperatuse in Veshgation of Trendelenburg position for pro phviaxis Am Surgeon 17 703 1951 13 Foley W T and Wright Is Long term antı coagulant therapy for cardii ascular diseases Am J M Sc 217 136 1919 14 and Wright I S The use of dicunasol in obce practice New York ved 6 16 1950 15 and Wight I S Pulsonary thromboem bolism diagnosis and treatment New York State Ved 52 1994 1950 16 Wilags RW and Stanton I R Elashc stack ings v the prere tion of pulmonary embolist New Englard Med 248 1097 1953 17 Arusely WH ar d others American Heart Assor 29th Scientific Session October 1956 Ciornata GENERAL READING Wht ! S Vascular Diseases in Clinical Pran tice 2nd ed Chicago Th Year Book PubLshers Inc 19) Allen E Basket Yaad Hines E AJ Teripheral Vascular Diseases vnd ed Philadel pha B Saunders Company 1915 Foley \ T and Yoght Is Long term and roagulart therapy for cardiovascular di eases Am J M $c 217 138 1949 Ohio p 86

·62
Venous Diseases
Case 30 Pulmonary Embolism, Migratory Phlebitis, Carcinoma of Pancreas
gre
Certun types of carcinoma seem to de
range the blood clotting mechanism and
rise to intravascular clots Perhaps carcinoma
of the pinerens is the most apt to do this as
Was pointed out by Trousseau nearly a century
ago Carcinoma of the lung stomach breast
and met istuses to the liver are also frequently
associated with clotting
Case 30 wis 1 middle aged man who de
veloped phlebitis and pulmonary embolus
while crossing the Atlantic on a ship The con
dition was quickly controlled by anticoag
ulants when he arrived in New York
Phlebitis recurred while recening thieri
peutic doses of documıro) This is character
istic of phlebitis associated with circinoma
However it does respond to parenteral he
parın We were so convinced that this patient
had a hidden cucinoma that we urged a lap
arotomy even though all diagnostic chemical
and x ray procedures were essentially normal
At operation a circinom of the tul of the
pancreas with extension to the liver and peri
toneum was found

·w Lymphedema Lymphederna often presents a perplexing problem in diagnosis and management The diagnosis is often confused with cardiac and renal disease Treatment may be thereby mis directed or delayed and the condition worsens often irrevocably The purpose of this short chapter is to assist in the early recognition and proper therapy of lymphatic disease TREATMENT OF LY VPHEDEVA This depends upon complete cooperation between physician and patient in applying physiologic and psychologie principles over long periods of time It requires the applica tion of methods which are often uncomfort able and tedious The physician should maintain a degree of optimism and patience which will test him in the face of little or very slow improvement At times rapid provement occurs especially after recent thrombophlebitis and in some cases which involve the arm However in lymphedema of the leg the objective may resolie into simply preventing a worsening of the condition in many patients without proper therapy the edema progresses to elephantine CLASSIFICATIOV The 1953 edition of the Nomenclature and Criteria for Diagnosis of Diseases of thic lleurt and Blood Vessels (8) definas and classific's lymphedema as follows Lymphedema This refers to edema ni sulting from obstruction of the Ivmphatic flow Viicroscopically the early changes consist of dilatation of the lymphatics and widening of the tissue spaces due to edlem? In longstand ing lymphedema there is proliferation of the connective tissue often a variable degree of inflammatory cell infiltration pigmentation and fibrotic thickening of the dilated lymph atics Clinically the changes can be correlated with the fact that at first the edematous tissue is compressible (soft cdema) but later the swollen tissue is firm (so-called brawny in Quration or hurd edema) It is characteristic ally pale in contrast to the cyanosis or rulor seen with renous stasis The term elephantiasis 35 used for the grotesque deformities of the more severe types Lymphedema may be pri mary or secondary but the former s Leiter designated as idiopathic 65 Size

·No text on this page.

·po) ankle 67 Clinical Features Clyricteristicalls edema stirts in one foot Table ! Diferential diagnostic features LYNPAEDENA THROWBOPHIEBITIS ind ankle At first only 1 shught puffiness is Color of leg Pale Usually slightly c) asotic present Grdurlly it increises spreuling up (honzontal the leg sometimes intoling tissues of thic tłughs and buttocks It may be unilateral for Sets Usually ha Collateral seins often ming yours before starting in the other kg din by prominent If patient ed a has ha previous at In the beginning the edem? is reduced dung tacks varices may be thic night and desclops during the making present as well as pleri hours when the patient is up Any constructing usually around the sorment such as circular girters or girdles causes it to increase peripherald Corelles arc Pigmeat Tone In presence of long deposits standing enous insul particuluh inimful for thics se designed fat ficiency there is often women in the upright posture onl lllien much broue hemosi kamen sit the girdle stretches crertins pres derin deposit Tround ankles and shins sure across the groin ind it acts as a tourni Infamation Cells Ped het terder senow quet to impeclc lymph flou Sitting for mini usually dif cords are pathogno hours in vehicles thcaters, or at cure playing fuse and monic but with deep sessions is a strun on even a normal lymphs often broht thromboses these may sistem red not be discernible Good lymph flow requires body movement Tenderness one etcept Varked tenderness to in presence deep pressure Ho Durmg actre sports or walking the rem of cellules mans sign is some tends to decrease Walking in decp water pro times present of deep duces the unique situation of a maximum com calf veins are insolved pression pressure at the foot decre using The etrology of edema of an extremity fol progressively up the leg when tles is com louing surgery is a controversial subject (3) binud tsith the pumping action of muscular Cancer may invade and block the lymphatic motion it presents an ideal method of squecy depots The surgical and radiologic destruction ing Rund out of the leg Swimming is the best of main lymph channels often leases insufh sport for these patients cient patent vessels for adequate drainage The etiolony of lymphedema praecor is Fluid accurulates in the tissue spaces In timº completely obscure Clinically at scems as of there is a connective tissue proliferation that there were a congenital blochage of the lymph converts the boggy areas into a fbrotic mass chunels or simply that the total lymph drun The most common form of swollen leg we age system is not efficient enough Kinmonth are called on to treat is that of kumphedema praecox This condition usually occurs in young and Taylor (6) have shown that the lymph trunks are dilated and the vales dcfcctine Be uomen rarely in men ſhe ratio is about 10 to I but the cause for this difference is not under cause of the frequent episodes of cullulitis the condition is often confused with thrombo stood It develops most frequenth shortly after the onset of the menses Occasionally at phicbitis The table of differential points * fast minufested as late as 40 years of age (Table 1) may be helpful in establishing a The later it appears the milder it is apt to be diagnosis (5) A familial lymphedema (Mit although some early cases do not progress to TOY S disease) des clops in a similarly inexplic 1 serious degree able manner This may involve onc or more extremities of half the body ·66 Classification of Primary and Secondary Lymphedema A Primary or idiopathic lymphedem? 1 Congenital (Milroy s disease) This is a hereditary congenital nonp unful lymph edema mvolving all or part of one or two extremities It may be unilateral involv ing the upper and lower extremities and rarely additional urers may be involved 2 Priecor This refers to ? clinical syn drome affecting young females much more often than males The lymphedema usually appears bets cen the ages of 15 and 35 involving first the feet Inter ascending to invoke the legs and thighs B Secondary lymphedema is due to 1 Surgical remos nl of lymph nodes 2 Neoplastic invasion of lymph nodes esther by primary or metastatic neoplasm 3 Lymphadenitis following 1 \my treatment Fibrosis and scarring enhanced by x ry may cause obstruc tion of the lymphatics and resultant edema b Pyogenic infection c Granulomis due to (1) Filarasis (2) Lymphogranuloma vencreum (3) Tuberculosis (4) Syphilis 4 Dependent edema Edema of the legs may follow prolonged sitting is during long trips by nuto rail or air It has been reported in persons seated for miny hours in air raid shelters Some complicating fictor is usually present such as a girdle »hich folds and binds the groin when seated or 1 chur with a firm edge that presses on the thighs If the edema is prle the obstruction is lymphatic If at 1$ cyanotic i complicating phlebitis may Lymphedema CLINICAL FEATURES The most common form of lymphedema of the arm follows radical mastectomy A study of this subject was published in 1951 (3) This type of lymphedemi is characteristically a progressive disabling and often punful con dition In some cases the swelling occurs shortly after operation in others edem for mation may not desclop for as long as five years It usually appears first in the line and accumulates proximally although in some of our patients the reverse has been true The increased weight of the arm pulls on the nerie roots causing i neuralgin The pun often dis appears when the swelling is reduced by treit ment Swollen arms and legs ure nestheticalls dis turbing They may be devastating to the ego of others se well ndjusted women Several of our patients hue been recluses until reduction in swelling encourged them to abandon their seclusion The deformity has resulted not in frequently in marital difficulties Excn minor degrees of swelling muv bc sufficient to deep women from engaging in activities requiring a costume that reveals the abnormality Edematous extremities are very often the site of attacks of cellulitis and crysipel is le first saw one patient in his one hundred and fourth attack which had occurred over 1 31 veir spin He had lept records of bis attacks in numerous hospital stays It is apprent from this clinicnl obser ation that tissue immunity is reduced in those areas with slow lymph flow The fact that lymph flow is slow is readily demonstrated by the intricutancous injection of dies in the minner described by Vicilaster (7) A simple furuncle that is quickly healed in 1 normal arm may become a large spread ing infection in one with lymphedema Fungous infections splitting the shın permit infections to enter and we frequent complicating factors They must be rigorously controlled Cleation moist heat and appropriate intimicrobial drugs arc usually quickly curative be present ·69 Folcs chastic skics Medical Management quire a garter belt to hold them up They are strong enough to gne adequate support for mild or moderate cases but still light enough not to huckle The elastic sleeve wluch 1195 described previously (31) has been improved by use of the new orlon materihl The slecie should start at the base of the fingers and should have an opening for the thumb Irge enough to ge at full play A pressure of 40 mm of mercury at the distal end of the sleeve grad ually falling to 15 mm at its termination in the upper one third of the arm is adequate compression See the accompanying dlustra tion Sometimes the fingers become vers swollen A rubber glove wom with the sleeve may help to correct this Physiotherapy Massage in the direction of the lymph flow toward the heurt increrses the speed of flow We recommend effleurage each evening for 10 minutes self administered While in the hospital massage may be formed more frequently The Jobst Company together with Brush and Heidt (12) hase developed a tight sleeve lined with inflatable balloons The balloons are nitemately inflated by a pump which Horks on an automatic device we have found it of help in milking out" the fluid in lymph demnatous arms and legs Although this may be a temporary gain it aids in promoting the efficiency of lymph flow Hydrotherapy in the form of walking in deep water is of great value in forcing cdema fluid from legs and has already been mentioned under Clinical Features" Dehydration The disappearance of edema hud can sometimes be hastened by a low salt diet and daily diuretics We employ a 2 gm par salt diet and dul injection of 1 to 2 ml of thiomerin Flunds are not restricted Thus reg men is maintained only during the first week of hospitalization Activity Patients are encouraged to re sume full activity and sports wearing thier elastic stocking or slees. The pumping action of muscular movement on venous retum und lymph flow is well known Additional measures have been sulgested as follows 1 Buried suturc technic of Ilanelley (5 9 10 11) 2 Hyaluronidase (1 2 11 13) 3 Sympathectomy In our cxperience all three have fasted to pro duce improvement and sympathectomy often makes the edema worse It is definitely contra indicated ·68 MEDICAL MANAGEMENT The judicious application of sound physio logic principles is the essence of treatment of lymphedem? Gravity Edemy of the arms or legs is in imbly reduced by prolonged elevation which is is readily demonstrated reduces venous pressure and increases the speed of lymph flow Elevation of the lower extremities is easily accomplished by placing blocks under the bed posts at the foot Sıx to eight inches is the maximum elevation tiint is well toler ated Rusing the entire foot of the bed in this manner is much more comfortable and far more practical thin either ruising the mattress hlone or placing pillows under the legs The new type wedges placed under the low er half of the mattress rre apt to produce low back strun unless the patient sleeps constantly on his back Patients who sleep with their legs properly elevated recere good lymph drin nge in the legs for at least one third of each day Sleeping with the arm in maximum elevi tion is a much more difficult problem After ? number of years of experimentation with various measures and methods in ipprratus was designed to muntun the arm in maximum clev ntion and to allow the patient to move about in bed is well as from side to side (see illustration for Case 34) This is primarily in tended for patients in whom the swelling rep resents a serious situation This apparatus uses the principle of traction with enough counter weights to balance the arm exactly it is most important that no constricting bandages be used to attach the arm to the traction appar atus Under tension these bandages will act is tourniquets Instead foam rubber pads are loosely applied to the arm by in elastic band age The friction of the form rubber gainst the skin is enough to secure it A halter snap allows the patient to disengage herself quickly from the apparatus Lymphedema Beforc placing any limb in cletation onc must be certain that the arterial supply es ade quate In the presence of arterini insufficiency grave damage may be donc ly elev tion of the part If the radial or pedal pulses are pres ent and pallor docs not develop in the toes or the fingers on elevation it may be assumed that adequate urternal flow is present Inter ference with the radial pulse is sometimes caused by changing the position of the arm This pulse should be palpated in the position of extension to be sure of its quality (test for hyperabduction and scalenus syndromes) Most frequently satisfactory reduction in the size of swollen arms can be obtained in women who have consented to enter the hos pital for the inception of therapy There mari mum elevation cin be applied without interruption Patients learn the therapy and cooperate more fully than if they are simply given instructions to carry out at home If however they are unable or unwilling to con tinue their regimen at home they may Jose a part or all of their improvement Compression Edema fud druns out of the extremities in elevation but it tends to reaccumulate in dependency To prevent this elastic stockings should be wom on the legs or an elastic sleeve on the arm when the pa tient is up and about The stocking should be made to measure It should fit snugly and start just above the toes The foot oren should give a compression of 40 mm of mercury The pressure should gradually fall as the stocking progresses tip the leg In most cases the stocking may end just below the bend of the knec When edem? of the thigh is also present the stocking should continue nearly to tlic groin Mlost long stockings tend to buchle in back of the knee ghing tourniquet effect in the popliteal space on walking or especially on sitting Recently orlon stockings luzie appeared on the market Long ones of this material re ·09 Foley clastic skcie Medical Management quire a garter belt to hold them up They are strong enough to gae adequate support for mild or moderate cases but still ught enou „l not to buckle The elastic sleese which has described previously (3 $) has been improved by use of the new orlon materır! The sleere should start at the base of the fingers and should have an opening for the thumb large enough to ghe it full play 4 pressure of 10 mm of mercury at the distal end of the sleeve grad ually falling to 15 mm at its termination in the upper one third of the arm is adequate compression See the accompanying illustri ton Someten the fingers become sery suollen A rubber glove wom with the sleeve may help to correct this Physiotherapy Massage in the direction of the lymph fox touard the heart increases the speed of flow We recommend cfleurage each esening for 10 minutes self administered While in the hospital massage may be per formed more frequent)s The Jobst Company together with Brush and Bleidt (12) have developed a tight sleeve lined with inflatable balloons The balloons are alternate) niated by a pump which works on an automatic device We have found tt of help in milking out the flu in lymph cdematous arms and legs Although this may be a temporary gain it arcis in promoting the efficiency of lymph flow Hydrotherapy in the form of ning 20 deep water is of great value in forcing edema furi from legs and has already been mentioned under Clinical Features Dehydration The disappearance of edema fluid can sometimes be hastened by a low salt salt diet and daily injection of 1 to 2 ml of thomerin Funds are not restricted This rega men is maintained only during the first week of hospitalization Activity Patients 150 encoured to re sumt full activity and sports caring their elastic stocking or sleeve The pumping action of muscular moi cment on venous return and lymph flow is well known Additional measures have been suggested as follows 1 Buried suturc teclunc of Handley (5 9 10 11) 2 Hyaluropdase (1 2 11 13) 3 Sympathectomy In our experience all three have fuled to pro duce improvement and sympathectoms often makes thie edema worse It is definitely contra indicated Diet and daily diuretics We employ a 2 gm ·70 Lymphedema Casc 31 Massive Lymphedema of the Arm Mrs L E is 1 woman of 59 yeurs (The New York Hospital #647569) In 1912 1 left ridicul mistectomy was performed for car cinomu This was followed by deep in ther ?py There was no wound infection The arm commenced to swell shortly thereafter In one year it had rescheda Turge size A Kondoleon operation was performed The swelling recurred and the following year ? second kondoleon operation was performed The arm gradually became larger When first seen by us on November 19 1951 it had renched a massive size (see the left figure) She had developed intense root pun in the neck and shoulder The arm was “too heavy to carry vround She had become a recluse She was hospitalized and given the regi men of eles stron massage dehydration and compression outlined previously A very greit improvement was obtuned (see the right fig ure) in ? period of 12 days (December 31 1951) There had been a great loss of edema tous flud lering loose baggy skin (Table 2) The loose skin contracted slowly during the follow ing six months The root pun had dis apperred ind she was discharged from the hospital with instructions to sleep with the arm eles ated in the traction apparatus to wear the elastic sleeve during the day and to massage the arm eich night for 10 minutes This woman continues to follow our out line of ther ipy and has maintained the im provement loose baggy skin contracted to the size of its contents The cosmetic ? pearance has improved greatly The former great weight of the um v as relici ed and with it the pain from nerve root traction has dis perred Hy hluronidase fuled to gre further decrease in swelling Table 2 Measurements of circumference in centimeters for Case 31 LOCATION DATE 11 19 51 12 31 31 1 24 59 2 27 3 1 2 5 2 2 316 18 58 Hand 280 238 235 216 225 197 198 Maximum Forcamm 445 349 356 33 7 352 314 34" Vaximum Aon 52 1 399 378 352 371 368 367

·Case 31 Massive Lymphedema of the Arm
71
Enormous swelling of the
entire arm and hand
Twelve days later Patient
was treated by elevation mıs
sage and Foley slecie Swell
ing has largely subsided len
ing bags of pendulous skin
This loose shin shrank up slowly
during the following six months

·72 Lymphedema Case 32 Lymphedema of the Arm Mrs V J (The New York Hospital #128954) is ged 65 years A left ridıcıl mıs tectomy was performed in November 1945 for canalicular scirrhous carcinoma of the left brcast with no discoverable axıllary metz stuses Swelling of the arm developed follow ing operation It commenced first in the brachium Slowly through the course of the next three yours the swelling involved the lower rm wrist und hind The swelling usually subsided when the patient eles ated her ırm on 7 pillow hut during the two months immediately preceding vascular con sult ition the suelling apparently became inore fiica The patient was seen on Jul 8 1948 She was a tiny women and is as very apprehensne and disturbed about the ppearance of her swollen arm (see the top left figure) There was a large elliptical surgical scu across the left interior thorni cxtending into the sulla The axilla » as deep no nodes were palpable Oscillometric readings were normal The entire urm vs svollen The brncluum and lower arm were indurated and the sclling did not pit, although the land and fingers had a soft edem? which pitted readily Measurements are shown in Table 3 Treatment consisting of nightly elei ation effleurige and the use of an elastic sleeve and a snugly fitting surgeons rubber glove was started at once Four weeks later the swelling had entirel cleared in the fingers and hand The top right figure shows the Foley sleeve in place There kas mired reduction in the forc arm and arm The rubber glove was discarded After sur months the elastic sleeve WIS also eliminated On the patients last visit eight years after the start of treatment only a slight thickening re mained in the forearm and arm (see the bottom figure) She continues to sleep with the arm elevated Table 3 Measurements of circumference in centimeters for Case 32 LOCATION DATE 7849 728-18 12 16-50 Hind (abosc metacarpal bulge) 185 181 180 Wrist 150 147 Varmum Forenim 250 200 197 Vaximum Vidbrrchrum 22 0 270 210

·Case 32 Lymphedema of the Arm
73
Close
up
of arms and hands
Foley sleese in plice
Eight year follow
up

·74 Lymphedema Case 33 Lymphedema of the Arm Note suelling of hand and forc ΓΙm After trentment Note urin Kling of skin and repperrance of veins Miss M B (The New York Hospital #553102) is nged 53 A rdıcıl left breast im putation was performed for circinomi on October 14 1919 One month Inter swelling developed in the arm The nrei adjacent to the elbow became stiff and hard In May 1950 the hand and fingers became swollen The patient appeared for inscular consulta tion on May 26 1950 At that time the only abnormality was the surgical scar and the swollen arm For 1 distance of 10 cm above und below the elbow there is a woody dense edema The arm was pole and firm The upper arın uns swollen but soft while a very soft edema was present over the foreirm hand ind fingers (see left illustration) Oscillo metric studies were norm! The patient was not hospitalized She vis instructed to suspend the arm in maximum ele. ition it might wear in elastic sleeve and massage the arm duly The swelling left the fingers hand and wrist rapidly (Table 4), The right illustration shows the wrinkling of the skin and the reappearance of the veins The swelling has slouk subsided elsewhere On the patients last visit October 10 1951 the ure? round the elbow was soft Table 4 Veasurements of circumference in centimeters for Case 33 LOCATION DATE 5 26 50 10 18 50 10 10 54 Hand (nbose meth carpal bulge) 185 170 165 Wrist 155 150 150 Maximum Forearm 270 250 218 Varimum Brachium 284 280 276 ·Case 34 Lymphedema of the som Case 31 Lymphedema of the Amm Use of the Foley arm edema stand Virs AG is a 57 year old Italian American housewife (The New York Hospital $493717) In 1917 a right radical mastectomy was per formed for canalicular carcinoma of the breast with metastases to the axıllary lymph nodes There was no wound infection She did not Tecen e radiation therapy in 1950 the arn and hand became noticeably s ollen Swelling gradually increased On February 27 1953 medical therapy was started Swelling de creased during the course of the first ucek especially in the upper arm where it was most marked On March 9 and 10 wlod sutures were inserted One extended subcutubeously from the scapular region to the wrist the second from the supraclavicular arci to the midarın Hyaluronidase was given daily for one week in Ingh and ios dosages directly into the edemntous areas Only slight further improve ment was noted in the course of the next six months At that time October 3 1934 the metastases were found in the cervical nodes It is most interesting to obscrue that med ical management improved them even with the development of metastases The accompanying photographs illustrate the use of the Foley arm edema stand with the patient in various positions ·76 Lymphedema Case 35 Lymphedema Praccor NI for surgical treatment of this infection and responded well Wlule in the liospital in November 1951 two nylon sutures were im planted surgically by Dr William Terwilliger One extended from thic medıl side of the inkle to the groin and the second from the lateral side to the hip are i The cdemu fulcd to improve It was believed that perhaps the suturc lind not been Cirried high enough in January 1951 tuo Additional sutures were implanted from in drei of normal tissue below the ribs down cross Poupirts ligiment to the mid thigh Tlie edema increased slowly during the next 14 months She complained of tenderness in the groin upon bending at the u ust In April 1953 she was admitted to the hos pital and the sutures were removed At this time she was given an intensive course of liz zluronidasc injected duly into the edem? tous tissuc While in bed the edemr subsided somewhat but when up and about even with fier clastic support it recurred and reached its previous size Wlien last seen on November 14 1953 the odem wis slowly increising as shown in the illustration Note the uniform suelling up the entire leg This type of case is the most difficult to manage She was seen only ifter the edemi 175 massive A sympathic tomy had been performed As indicated be fore this lins now been found to be of no 1 tluc in uding lymphedemi Actually the surgical incision und dissection furthier impede ind damage the lymph channels Miss A Mer (The New York Hospital #014483) 1 23 ycır old stenographer wis first scen on December 22 1950 She gave a Instory of lizung devcloped selling in the right foot and leg in 1947 In June 1919 ? right lumbrar sympathectomy was performed in another hos pital As lins been repentedly noted with other similar patients following tlus procedure the leg ripidly increased in size Wlien first sucn slichid developed massive udlemi extending from the ai uist to the tocs on the rght side With mcdical management the cdumi was held in check during the next cight months A prronychi developed in the right great toe She was admitted to The New York Hospital

·77
Case 36 Lymphedema Praecos
Case 36 Lymphedema Praecor
MSI
Vote pale swelling from left
Side VIEWS
foot to thigh
Werring of Ince kngth clas
tic stocking is part of treatment
Viss NV (The New York Hospital
*639768) a 33 year old office worker was
first seen on October 10 1952 She had a his
tory of a graduallv enlarging left leg from toes
to groin over a thrce year period During this
time she had had several episodes of cellulitis
She was placed on the medical regimen
\o improvement was noted and one month
later a suture was inserted extending from 5
cm above the inguinal ligament to 10 cm
below it The following month she was given
a series of threc wcchly injections of layola
ronidase The left figure shows a front view
of both legs Note the pile swelling in the
left foot to thigh Thic middle figure is a sida
VILW The night figure is 1 front view showing
Inec length elastic stoching being mom as
part of her trentment (11) No dramatic im
provement occurred

·78
Lymphedema
Case 37 Lymphedema Praecox
Mrs RW (The New York Hospital
#292194) was seen in 1949 at the age of 42
Sce the pale swollen leg in the accompanying
illustration She gre z history of swelling of
the right inkle at the age of 18 The swelling
gradually increased in size until the leg be
cime cumbersome ind her? She was placed
on the medical regimen and obtuned some
improv cment The measurements decreased
and the leg became less tense One month later
she was admitted to The New York Hospital
Under general anesthesia Dr Jere W Lor
Ir inserted double strand No O nylon sutures
later illy and medially from the inhle to the
right louer quadront of the abdomen Slight
improvement was noted during the liospital
stly probably due to the prolonged clou ation
Her subscquent course his show n no improve
ment

·79
Case 38 Vassive Lymphedema Precor
Case 38 Massae Lymphedema Praccor
This young woman noticed swelling of her
right leg shortly after puberty The swelling
gradually extended up both legs and slowly
increased to its present massive size
The accompanying figure slous 1 front
view of both legs The greatls swollen left leg
hangs down on cr the ankle like n lng

·80
Lymphedema
Case 39 Lymphedema of Leg Secondary to Surgery in Groin
This 30 yer old woman had a rıdıcıl pel
vc operation with resection of lymph nodes
in her right groin for carcinoma of the cervix
one and a half years ago Swelling of the right
leg commenced shortly after operation and
slonly increased in size
The allustration shows a front view of both
legs Notice the prle edema of the entire right
leg extending up to thc groin

·81
Case 40 Lymphedema of Hand
Case 20 Lymphedema of land
This 15 year old box has lymphedema of
the hand (see the illustration) When a baby
he fell asleep with a rubber band around his
wrist By the time his parents noted it some 12
hours had elapsed The hand was swollen It
continued in a swollen condition throughout
adolescence Trintment consisting of cles ition
and hydrotherapy has greatly improved the
condition

·82 Lymphedema Cases 41, 42, and 43 Stasis Ulcerations and Edem Large ulcerations of ankles and edemy of feet in a fur ac inced arthritic patient Ulcerations ind gangrenous areas in patient immobilized with arthritis Gangrenous heels from pressure of lying in bed ud immobility in patient with rheumatoid arthritis Sitting with the legs in dependency for long perods of time results in poor venous and lymphatic drainage Even in normal indi viduals the legs may become swollen With inadequate retum venous or lymphatic circui Intion this may at first be temporary After! period of months or years of relatie inactivity and sti5is the tissues break down and ulcera tions develop Prevention consists in having these patients walk if possible Treatment should be directed at the underlying arterial or venous condition An oscillating bed 15 often helpful The upper left figure shows stasis edem? of the feet and large ulcers of the ankles The major urterul and venous systems are nor mal This patient w is a fur dvanced artlıntıc ind had not walked in mini years The upper right figure shows ulcerations and gangrenous areas in a patient iminobilized with rthritis Old phlebitic lesions are present The major arterial supply is normal The ·Bibliography gan renous lesions sloughed and healed when motion was instituted The lower figure shows stasis eczema and 83 gangrenous heels uluch des claped from the pressure of lung in bed and immobility in 1 patient with rheum toid arthritis BIBLIOGRAPHY - 4 1 Britton RC and labu DI Clinical use of hyaluronidase Surgery 33 917 1933 Editorial Lancet 2 1072 1932 3 Foles W T The treatment of edema of the arm Sur Cynec & Obst 93 569 1951 An elastic sleeve for edema of the arm New lork State ] Ved 54 1052 1951 5 Handles W A Lymphangioplasty a new method for the relief of the brawun arm of breast cancer and for similar conditions of lvnphate edema Lancet 1 783 1908 8 Linmonth VS and Taylor C The lym phatic circulation in lymphedema, Ann Surg 109 109 1931 Vic Vaster P D The lymphatics and lymph flow in the edematous skin of human beings with carchac and renal disease ) Exper Ved 60 373 1937 8 Cnterin Committee of the low Jork llenrt Ascociation Inc \omenclature and Criteria for Dr nosis of Diseases of the Ileart and Blood case is 5th ed lex lorh low York leirt Assn 1933 PP 333-334 9 Ranshoff J L Surgical treatment of Impla cdema Arch Surg 50 269 1915 10 Ziemin S A Reestablishing lymph dramnge for lymphedema of the extremitas j Internt Coll Surreons 15 329 1921 11 Fols HT The treatment of lymphedemi Surg Gynee & Olst 101 25 195 12 Brush B E and Hedt T) A device for relief of lymphedema JAVA 158 34 1935 13 Vufson I Column L. Ridle Land Shacman V Treatment of edema with his luronidase New York State J Ved 56 2093 1926

·No text on this page.

·4 Vasospasm and Diseases in Which It Plays a Majoi Role When the body is chilled the peripheral If the medium sized arteries are thickened arteries and arterioles are constructed and from disease is in scleroderma atheroscler blood flow is reduced As time passes the on Osis obliterans or thromborngitis obliterans gen content of the peripheral blood is less the construction that occurs following chilling ened the lips ears nose hands ind feet mas ciuse complete oltriction of the entir become blue the arms and legs turn n mottled vessel A dead cida, crous white art 1 deel purple If chilhin is severe some areas may ops along the distribution of the arter if blanch Fever on the other hand results in the affected person comes into a warm room marked peripheral vasodilatation All pulses or increases his body lieat for example by become augmented The skin becomes hot taking a hot drink the spasm may be released pinh, and dry The blanched are is slowly change to blue as A slight change in temperature of a large the blood trickles through the capillary bed surface of the body or a profound change in and its origen is rapidly removed Soon a small area can evoke a vasomotor response bright red Aush appears as full culatation of either constnction or dilatation This is medi the vascular bed occurs (reflex luperemın) ated by refex nerous action If blood retum and blood cont uning large amounts of oxygen foods into the venules which influence in 13 to the vasomotor center in the brain is cooled peripheral vasoconstriction results Turge measure the color of the skin The control of the flow of blood to the peri Disorders of these mechanisms lead to set phery is somewhat similar to the thermostat eral chnical syndromes If periodic blunching regulating water flow in the radiator of an of fingers toes cars and sometimes the nose automobile above a given temperature the Occuts it is called Raynaud's phenomena water will be sent through the radiator (the or syndrome If blueness and coldness of the peripheral circulation) in order to expel heat fingers toes hands or feet occur for long below this temperature the water is kept cir periods of time then the condition is termed culating in the intenor of the motor (tke acrocyanosus If the most prominent feature is deeper tissues) to conserve heat mottling of the arms and legs with episodes of coldness and blueness as well it is called The familiar blush that follows embarrass licedo reticularis (Dermatologists call at cutis ment is evidence that emotional factors influ marmorata ) These conditions may be ence peripheral blood vessels Anger an] fear pri mary or they may develop secondarily to at produce a cool pale moist skin most any of the dozens of vascular diseases 85 ·86 Vasospasm PRIMARY RAINAUD S DISEASE This is a periodic blanching of digits, ears, and nose as expruned above It is precipitated by chilling or emotional stress it often starts in childhood ind lists until middle life It is far more common in women The abnormality is probably a function of the blood vessels themselves The arterioles are often the site of the construction Sever ance of sympathetic nerves to the vessel re sults in ? tcmporary improvement but Iiter the vessels usually regain their sensitivity to cold and emotion even though denery ited indicating that it is the vessel itself which is abnormal Hence sympithectomy usually provides only tempor in rclicf These patients should dress unusuall li armly They should ucar boots and gloves even on slightly chilly davs The apphcation of heat directly to the blanched part should be 10ded This may precipitate gingrene as in Cuse 44 A spasm of the large and inter medite sized vessels for evimple the radial ulnar and digital arteries can usually be quichly released by sarming the entire body Coming in out of the cold to a warm roo 11 or drinking a hot beverage are suitable mers lires Nitrogh, cerin under the tongue acts quickly and effectively to rele ise the sp 157 of the larger vessels but lius less effect on the arterioles RADIAL PULSE BEFORE NITROGLYCERIN THREE MINUTES LATER + Good effect of nitroglycerin upon pulsations of rdrul urtery in 1 28 yeir old patient with vasospasm associated with Raynuds disease Impalpable before nitroglycerin the pulsations became readily pripable after the druge • Denicotinized cigarettes impregnated with nitroglicerin duzte the penpheral uteries equally as well as sublingunl administration ?

·87
Case # Raynauds Disease
Case 44 Raynauds Disease
This
young woman had had cold moist
hands and feet since childhood On slight er
posure to cold her fingers would turn a ca
daverous white When she became warmer
the fingers would gradually turn blue and then
pink This change in color was blotchy Some
areas of a finger would be white while an
other area was tuming blue and still other
parts were becoming pink
At the age of 28 dunng a winter she sud
klenly experienced more frequent and longer
fasting attacks in her left second finger Dur
ing one such attack she soaked the finger in
hot water The need of the tissues for orygen
becime greatly incre used Blood flow as
insufficient to fumish it death of the tissues
ensued
The accompanying figure shows a close tip
of this finger which is necrotic
She was treated hy inducing fuser through
intravenous injections of typhoid incing
Complete healing was obtained in three
weeks tume She was advised to protect hier
self against chilling There have been no fur
ther episodes of gangrene

·88
Vasospasm
ACROCYANOSIS
This is a condition usually found in young
women The hands and often the feet ure
persistently cool moist and blue during the
winter Cold sweat may be profuse In sum
mer there may be some improvement The
skin shows little change except in color and
temperature Sclerodermi is never present
The churicteristic intermittent blanching and
ruboric phases of Raynuuds diserse do not
occur Puesthesii is a frequent complunt
Experimental studies of Lewis suggest that
it is probably the arterioles of the skin that
are affected The mechanism of this disease
rests in an unusual sensitivity of these vessels
to cold The larger and medium sized vessels
tre patent
Many of these patients are mentally or
emotionallı disturbed persons The condition
is not serious Gangrenous ulcers do not for
except from unhygienic practices or Overheit
ing Treatment consists in keeping the body
warm Vasodilatıng drugs have been disap
pointing Sympathectomy gives temporary re
lief only

·89 Case 45 Acrocyanosis Case 45 Acrocy unosis mama Table 5 Effect of nitrolycerin on pulses of patient with vasospasm and acrocyanosis TO 5 2118 BEFORE DILC AFTER DALG Vrs) $ (The New York Hospital #592 606) was 51 years of age For 10 years this middle aged farm woman had com plained of episodes of severe pain and numb ness in her hands and feet At such times they became a deep purple in color and were cold and wet Since childhood her extremities had been notably cool and moist All peripheral pulses were feeble Sublingual nitroglycerin gate relief for several hours at a time Table 5 gives the oscil lomctric readings in her foot The illustration shows the cy inosis and lack of scleroderma Blood pressure Pulse Rodzal pulse Ulnar pulse Femoral pulse Dorsalis pedis Posterior tabral Oscillometric font Oscillometric abosc ankle Ricirt LEFT 128/78 OS 2+ 2+ 0 0 2+ 2+ 0 0 0 0 0 0 Ricart LEFT 11870 72 3+ 3+ + + 3+ 3+ 3+ 3+ 3+ 3+ 05 0.5 20 20 40 40 ·90 Vasospasm LIVEDO RCTICULARIS Adolescent girls and young women some times exhibit a mottled blueness of the urms ind legs especially when they pre slightly chilled This represents a constriction of 1 few arterioles often associted with 7 flaccid dilo tation of the subcutaneous venulcs In long standing cases 1 nonspecific i asculitis is often found by biopsy This is usually accomp inied by increased vasomotor tone in the hands and feet The peripheral pulses become faint, the hands and feet are cold moist and mottled This condition is usually benign but often excites a great concern on the part of parents It my persist for ? decide or even two but usually decreases in severity thereafter Rarely small painful ulcers may occur Sum pithectomy is of little value and is unwar rinted Patients should dress warmly and ?101d chilling Vasodilatıng drugs are helpful but their side effects are usually worse than the condition itself but pile Case 46 Livedo Reticularis 11 This 20 year old girl had increased is omotor tone since early chuldhood Her hinds and feet were always prle cool and moist cxcept when the visospasm 25 relieved by ilarmth fever or drugs Pulses were faint On exposure to a breeze or i cool atmosphere a mottled purplish discoloration developed on her arms and legs The illustration shows a close up of the hands Note the blotchy discoloration

·91
Case 47 Luxedo Reticularis
Case 47 Liicdo Reticularis
In thus patient ulceration developed This
JU year old housewife had had blotchy pur
plish discoloration of her arms and legs since
chuldhood It was accompanied by greatly in
creased vasomotor tone
as manifested by
cool pale moist hands and feet and faint
pales
Llcerations began to appear 11 years ago
They were painful In the illustration note
the cyanosis and black gan_renous areas at
finger tips They recurred in cold weather and
healed up in warm weather This suggested
a frequently confused condition known as
pernio or chronic chilbluns Healing was ob
tained by artificial fuser therapy The in
creased vasomotor tone was successfully com
bated by the strict avoidance of even slight
chilling

·92 Vasospasm FROSTBITE, PERNIO, CHILBLAINS Overexposure to cold results in severe vaso v isomotor tone which in turn may produce construction If the exposure is such as to dermatitis intense itching and burning profuse freeze the tissues serious damnge to the res perspiration with cold climmy hands and sels muy occur This damage which may per feet and occasionally ulcerations sist for years manfests itself by increased Case 48 Frostbite (Chilblains, Pemio) This middle aged woman lid suffered frostbite of her legs 15 years previously Eich winter after this she suffered prin numbness and discoloration of her legs She showed a very markedly increased sasomotor tone the feet were cold pile to purplish and moist at all times Neither the dorsalis pedis nor the posterior tıbınl pulses were palpable Dunng the summertime she was reasonably comfort able but as soon as the cold weather begin she had great discomfort throughout the en tire winter except when she stayed indoors und kept herself wirm On examination it was found that the pulses became bounding after the sublingual administration of glyceryl tri nitrate indicating release from 1 severe de gree of arterul sp ism The figure which is a photograph of both legs shows the intense redness ascending to the knees where it became streikDespite the immediate response to nitroglycerin this patient did not respond therapeutically to iny of the vasodilatıng drugs A bil iter al Jumbur sympathectoms was performed ind in excel lent response obtamed The feet bec ime warm dry ind pink and her discomfort dis ip peired A five year follow up finds her in continued good health When the ulcers of pernio are developed the long term effects of sympathectomy ure not usually sitisfictor)

·93
Case 49 Frostbite with Ulceration
Case 49 Frostbite with Ulceration
This 28 yer old telephone operator durel
oped frostbite of her hands six years preu
ously All of the fingers healed except for the
tip of the left index finger which became
necrotic and open ulcers appeared
The illustration is a view of the hand
showing the necrotic finger tip
In this patient healing was obtained by
fever therapy The patient was given a course
of induced fever theripy using intras cnous
typhoud vaccinc The first injection was
5 000 000 bacteria A slight chill was obtained
with a rise in temperature to 101° F Tlic ck
vited fever continued for three days A second
injection was given Again a fuver was ob
trined for several days A total of four injec
tions in a two wech period resulted in healing

·94
Vasospasm
Casų 50 Frostbite
U
Ten days after freezing
Tour months later
Thus 28 year old registered nurse went
sking in January 1957 in Canada in frigid
weather She come in for lunch and noticed
that her hinds were red and cold Her left
thumb tingled and liurt
She shued ngun in the afternoon return
ing it 4 30 pm The thumb was white By
nightfall it hnd turned dirh purple
The treatment consisted of 7 petroleum
jelly dressing and the administration of oral
priscoline Hot sonks and heat to the thumb
were scrupulously noided
The left figure was then 10 days after the
incident Note the purple area under the nail
ind in the soft tissues
l'he right figure was then four months
Inter The deid shin areas have been replaced
Nul regrowth is still incomplete

·Case 51 Frostbite
95
Case 51 Frostbite associated with Acuros ascular Syndrome of the
Shoulder Girdle
This 15 year old outdoor laborer des cloped
frostbite with gangrene of the tips of fingers
2 3 and 5 Examination revealed a significant
chime in the strength of his radial pulse in
various positions of the arm In a position of
moderate hyperabduction the pulse vanished
It w is dampened by the costoclavicular mun
ellier and by turning the lead sharply
Patients whose blood flow is reduced in
vious positions of the arm ac apt to develop
frostbite on mild exposure to cold

·96 Vasospasm enon SCLERODERMA This is a chronic disease of collagenous the pathologic slides was found to be con tissue that may remain localized to the skin sistent with the diagnosis of scleroderma for years or may involve every orgin For A diffuse fibrosis of the lungs may occur many years its chief signs may be those as Mfr T (see the lower figure for Case 56) had sociated with vasospasm The first sign of the had scleroderma for some 10 years Sympa disease miy be typical Raynruds phenom thectomies had been done to no avul This procedure is uscless in this disease although Gradually the skin of the fingers thichens it is still being done in some areas He flen It becomes tout shiny glazed white and to New York for consultation The slightly cool Small painful trophic ulcers occur at rirified air of the urplane cabin pressurized the finger tips which heal slowly leaving small to 8 000 feet was sufficient to produce acute dimples in the skin The tissues contract pro oxygen lack and giet distress ducing flexion deformities Later the skin of These patients gradually resemble one in the arms legs feet face and torso thickens other and appear as if they were siblings In far advanced cases even the breast ab domen and thighs are affected The lips be TREATMENT come thin and drawn The mouth cannot be There is no specific therapy The disease opened widely may become stationary at any stage ud is Slight exposure to sun produces wide subject to remissions and exacerbations What spread dense deposits of melının on exposed ever drug is being used just prior to a remis surf ices which do not fade Telangiectasis de sion may get the credit for the improvement velops on the face hands anterior chest and In the past three decades reports of success elsew here The bones in the terminal tufts of with treatments have been published Critical the fingers tend to become absorbed Entire analysis however has fuled to confirm the phalanges and metacarpal or metatarsal bones lue of any Testosterone ACTH cortisone can dis ppear AT10 vitamin D PAS und 1 host of vasodilat Calcium is deposited in the bursae about ing drugs have been tried Acute phases of the the points in tendons and sometimes in tissue disease such as intestinal obstruction seem to spices These may ulcerate and protrude respond to steroid hormones at least tempo through the skin rarily Difficulty in swallowing is frequently ex The precrutions agunst chilling (outlined perienced This is due to a thickening of the above under Runruds disease) should be esophageal wall A diagnostic pattern is seen Cirefully observed with the advent of cold on x ray examination of the esophagus with weather very punful ulcers form on the barium The small intestine is sometimes in fingers and are difficult to heal Such patients volved resulting in diarrhea and obstruction art frequently he ped by living in the tropics We have one patient who had 10 feet of in - it least during the six months from Novem testine resected Scleroderma was not sus but to April pected at the time and the pathologist had As stated previously sympathectomy is of not been able to establish a satisfactory diag no avail \\ hilc it may cause temporin warm nosis of the specimen One year later when ing of the hands the vessels soon regun their we saw her she had developed the typical susceptibility to cold Ulcers form and the tight skin of the face and hands A review of course of the disease is unaffected ·97 Case 52 Advanced Scleroderma Case 52 Adı anced Sclerodermi Note tight shiny shin and deposits of melanu Vouth open to full extent Note tight thin lips tout shm Over check bones and great limitation in opening, the lips This 30 year old woman had developed yasmodic blanching of her fingers five years efore Tuo veirs ago the skin of her hands recime tight and shiny The left figure shows the tight shiny skin The motion of the fingers was greatly limited » the skin contractions and became fixed in claw like position There was also discolora ion by deposits of melanın The right figure shows the mouth open to its full extent Note the tiglit thun lips tlic taut skin over the cheek bones and the great lunitation in opening the lips This often produces dental problems and in rare cases the angles of the mouth have had to be split to permit extraction ·98 Vasospasm Case 53 Advanced Scleroderma appearance ? This 40 yeur old housewife has had symp toms in her hands for more than seven years The disease started first with blanching of the fingers upon exposure to cold She noted that when she went to the icebox to take out 1 bottle of milk or if she went out of doors unless thoroughly protected agunst cold the fingers turned white In the summertime if she bathed in chilly water the fingers blanched When she came in out of the cold or took a hot drink the whiteness give way to blueness ind in turn to bright red discoloration As the years pussed the skin of the fingers and toes became shiny and tight Later this tight skın became apparent also on the arms and on the face Each summer when her skin tinned the pigmentation remained through the fall and winter fading very slowly The upper left figure is a close up of the face This shows marked tightness and shini ness of the skin The lips are very thin red spider like hemangiomis are present These are quite characteristic of the late stages of sclerodermi The upper middle figure is a side view Notice how shiny the skin is and how tout it is over the bones of the arm The upper right figure is a posterior view Note the tight skin over the scipulre which flare out from the body This posture is charac teristic in advanced cases The lower figure shows the hands The five characteristic points of scleroderma are well illustrated here I the clan like the lack of motion in the joints--this is not due to any urthrodesis of the joints but is rather due to a constriction of the skin and soft tissues about the joints 3 there are some areas of ulceration and scarring over certun of the phalangeal joints notably over the left second 4 areas of pigmentation and depigmentation are seen at the base of the right second and first fingers 5 churacteristic clubbing which follows prolonged atrophy as seen in the tip of the right third finger | ray study shows absorption of the tufts of the fingers and the deposition of calcium in subcutaneous reas and in tendons in bursal zones

·99
Case 53 Advanced Scleroderma
lote tight shiny shin thin
Lips and red spider like hemin
gomas
Aote tight shiny skin Oler
the arm bones
Note flining of the scapulie
FO
Note tight shiny skin clawlıhe appearance
areas of pigmentation and depigmentation im
mobility of joints areas of ulceration and
scarring

·100
Vasospasm
Case 54 Curly Scleroderma
AKT
This 58 year old housest ife noticed six
months ago that the skin of her hands and
arms had become much tighter and harder und
more shiny than formerly Exposure to cold
produces blanching and purplish discoloration
of the fingers and lands There is increased
rigmentation in areas esposed to sunlight
This cise is quite charcteristic of the dise ise
in the early stage (sce the illustration) when
the dignosis is frequently missed Such cases
frequently sturt as Raynauds disease and years
may pass before the scleroderma becomes ob
vious An curly fluoroscopic or ry examina
tion of the esophagus with a barium swallow
may show the characteristic stiffening of the
rugil folds and peristaltic waves

·101
Case 55 Adianced Scleroderma
Case 55 Advanced Sclerodem a \fan
This patient is a 33 year old salesman from
Texas This is of interest because of the mod
erate to hot climate Fifteen years previously
at age 18 he first developed episocks of
Ravnauds syndrome Bs the age of 22 it was
noticed that the skin of his fingers and hands
su quite thickened A bilateral cervical
thoracic sympathectomy was performed No
benefit was obtained and second bilateral
cervical sympathectomy was done This too
failed to produce any improvement This is
quite chrracteristic of the effect of simpa
thectomy in this disease There may not usion
ally be warming of the skin for several inontlis
but the unckr]yang disease progresses inex
orabls without ans effect from the sympathic
tomy
The left figure shows the di inced sclero
derma in the face and chest
The night figure is a close up of the lands
Notice the tight shiny skin and the clzulihc
position of the fingers

·102 Vasospisin Case 56 Far Advanced Scleroderma with Pulmonary Changes Radiograph of hands showing osteoporosis Extension of hands limited by tight skin und absorption of tufts Radiograph of chest showing extensivc pulmon iry fibrosis m both lungs This middle aged man had noticed tight The upper left figure shows the hinds to ness of his skin two years previously In addi be white tight and shiny They irc citended tion le hd developed spasmodic blanching to the fullest extent possible Note the limiti of the fingers and tocs upon erposure to cold tion of motion of the joints This limit ition is As the months progressed he noticed incre is due to the tight skin ing shortness of breath He decided to fly to The upper right figure is un vray of the New York for consultation En route in the hunds showing ostcoporosis Note the com reduced orygen tension of the high altitude plete absorption of the dist il tuo turds of the he became acutely Il from orygen lach und termin al phalanx of the right thumb This is almost cipired on the plane Upon admission quite chimicteristic of sclerodermi to the hospital his vital capacity was found to The lower figure is un vrai of tlic chiest be greatly reduced ud slows c\tensive pulmonary fibrosis in both lungs

·103
Case 57 Early Scleroderma
Case 57 Early Scleroderma
Ou
Tight shins skin of hands
Characteristic telangiectasia
and
pigmentation of face
This 40 year old secretary had hid Rav
nauds phenomena for one year Examination
disclosed sclerodermatous changes in her
hands arms face chest and legs
The left illustration is a view of the fice
and demonstrates the telingiectasia and pig
mentation which are charnctcristic features of
this disease ller mouth is opened to its fullest
extent but is not as limited as in the other
cases of further danced discase
The night illustration is a close up of the
hands showing the tight sluny shin Thic joints
are stuff but no contractures have yet de
scloped

·104 Vasospism THROMBOANGIITIS OBLITERANS The desclopment of spasmodic blanching made for the other stigmis of the disease eg of the fingers is sometimes the earliest sign of a blocked ulnar radial dorsalis pedis or this disense IVhen observed in an adult male posterior tibrul arten or 1 histon of recur below middle age 1 cireful search should be rent phlebitis in a smoker Case 58 Thromboangutis Obliterus Gingrenous brunds before therapy Healing after therapy SL This is the hustory of a physician in cul middle age Before we first saw him he had hnd three attacks of superficral phlebitis le then developed spasmodic blunching of the fingers ud toes after slight chilling of the body Ulcerations developed on the finger tips Evimination showed sluggish radials and occluded ulnars He was hospitalized He had been accustomed to smoking 20 cigarettes daily but stopped this habit completely dur ing the first hospital day He was given fever therapy in the form of intravenous typhoid vaccine Using a dilution of 100 million organ isms per ml five million bacteria were giien the first day Four hours Inter he had a slight chill followed by a fewer of 101° F We pre fer to obtain two to three degrees of fever without a chill but this is not always possible The temperature remuned elevated for two days On repetition of the treatment no fever was produced The dose was therefore in creased by three million organisms es cry fourth day Healing was well advanced 111 three weeks at which time he went home I returned to a busy general practice For some succeeded in wording tobacco However during a period of great stress be resumed smoking The disease prompth be cime actie und neu ulcers appeired The left figure shows the gangrenous hınds The radial ulnır dorsalis pedis and posterior tubiil vessels were occluded Because of the intense pain he had become addicted to narcotics He was agun admitted to the hospital With great difficulty he gave up tobrcco Narcotics were reduced then successfully omitted Again fever therapy was gren Col lateral flow des eloped and good heiling was obtuned with only minor loss of tissue as shown in the right figure If he should resume the use of tobacco the disease may be expected to involve other ves sels such as the brachial ilaç coronan ccre bral or mesentenc arteries ·Neurovascular Syndromes of the Shoulder Girdle 105 ATHEROSCLEROSIS OBLITERANS The digital vessels may be narrowed be the collntcr il teries Because of the an catuse of atheromatous deposits Slight chilling cronchment on the lumen of the atherosclerotic of the body produces constriction of those of plaques the constricted sessel may be comic the affected vessels that are still el ustic and of totally occluded Spasmodic blinchmg results NEUROVASCULAR SYNDROMES OF THE SHOULDER GIRDLL The large vessels and nerves pass from the vascular structures between the chuck and thorax to the arm In so doing they traverse the first rib narrow areas between bones muscles and tendons Slight abnormalities in structure or SCALEVUS AVTICUS SINDROMC in dynamics can lead to pressure or stretching of the vessels or nerves Episodes of vasospasm The scalenus anticus may be hypertrophed and paresthesia may result Even thrombosis or in an abnormal position It may compress of the subclavian vein or artery can be pro the nerves and blood vessels in rious post duced tions of the head and shoulders A certical rib even rudimentary muy en croach on the vessels or nerves in certain HYPERABDUCTIOV SINDROVE positions This may occur in sicep 15 in Case 59 or COSTOCLAVICULAR SYNDROVIE in certain occupations such as ceiling punting Relaration of scalenus and other neck plastering muscles may result in pinching the neuro or

·106
Vasospasm
Case 59 Hyperabduction Syndrome
This 52 yeur old clerk developed blueness
numbness ind tingling of the right second
third and fifth finguis The fingers were coll
The responses to light touch and pin prick
were diminished (upper left figure)
With the hands at the sides his ridil and
ulnar pulses were palpable When the hands
were raised over his head the pulses dis
appearcel It des cloped that he had the habit
of sleeping with his hands in bich of his head
He was instructed to sleep with his lands at
lus sides Prompt and marked improvement
resulted (upper right figure)
The lower left figure shows an anatomic
dissection of a fresh cider before contraction
of muscles his set in It shows the relation of
the willary artery ind brichul pleuus to the
Prins in ? position of relied abduction
Neres und vessels are under no tension or
pressure
In the lower right figure the um has been
placed in hyper abduction Notu how the vcs
sels ure stretched around the coricoid process
ind pinched between the clavicle and first ribo

·107
Case 59 Hyperabduction Syndrome
Cyanotic pregangrenous fingers
Fingers pink following therapy
M
Arm in position of relaxed
abduction
Arm placed in hyperabduction

·106
Vasospasm
Case 59 Hyperabduction Syndrome
This 52 year old clerk developed blueness
numbness and tingling of the right second
third ind fifth fingers The fingers were cold
The responses to light touch and pin prick
were diminished (upper left figure)
With the hands at the sides his radial and
ulnar pulses were palpable When the hands
were rused over his head the pulses dis
appeared It developed that he had the habit
of sleeping with his hands in back of his head
He was instructed to sleep with his hands at
his sides Prompt ind marked improvement
resulted (upper right figure)
The lower left figure shows in inatomic
dissection of fresh caduver before contraction
of muscles has set in It shows the relation of
the axıllary artery ind brachial plexus to the
arms in 1 position of related abduction
Nerves and vessels are under no tension or
pressure
In the lower right figure the arm has been
placed in hyperabduction Note how the ves
sels are stretched around the coracoid process
und pinched between the clavicle and first rib

·109
Case 60 Axillary Vein Thrombosis
Affected hand puffy and cyanotic
F
Arm swollen skin shiny and
Foley elastic slecic in place
blue

·108 EFFORT SYNDROME The axıllary vein may be damaged and may thrombose from sudden repeated force ful muscular contractions as in pitching hay This has been called the effort syndrome Vasospasm It is due to traumi on the qullary sein bu various structures of the shoulder gırdle AVILLARY VEIN CHROVIBOSIS Another erımple of a shoulder girdle syn drome is illustrated by Case 60 Case 60 Axillary Vein Thrombosis This 42 venr old Inborer fell and struck his right shoulder Following this the arm be cume swollen punful and cyanotic When ever he attempted to use it motion was quite painful Evamınıtion disclosed normal pulses and normal oscillometric readings The cir cumference of the arm forearm wrist and hand was increased With the arm in de pendency mottled cyanosis became apparent The collateral veins over the interior shoulder and pectoral ver were markedly increased and dilated The upper figure shows the hands The affected hand is puffy and bluish The swelling is indicated by the marked decrease in the wrinkles over the first phalangeal joints The lower left figure shows slight swelling and cyanosis with the um in dependency The lower right figure shows the Folev elastic sleeve in place This sleeve is designed to exert compression on the tissues and to limit the edema Treatment for this type of cise consists in elevation of the arm The arm is suspended in triction in ? comfortable position and with counterweights which just balance the weight of the arm so that the patient is able to move about the bed or if seated to move about in the chair without difficulty or discomfort This continued elevation results in a marked de crease in the venous pressure together with an increase in return lymphatic fou The ede ma is soon cleared However mıy months trinspire before sufficient veins rec inalize and adequate drunnge is obtuned Anticoagu lant drugs help to prevent further extension of the thrombus peripherally They also pre vent the development or extension of proximal thrombi which may embolize To summarize treatment consists in 1 anticoagulant therapy 2 elevation of the affected limb 3 compres sion with elastıc bandages or sleeves and 4 hydrotherapy with cool baths and whirlpool baths are helpful

·111
Case 61 Phlebitis
Case 61 Phlebitis (with Gangrene Secondary to Vasospasm)
This middle aged woman was admitted to
the hospital with the extensive gangrene noted
in the left figure with a presumptae diagnosis
of arterial embolism Careful examination dis
closed that the primrry lesion was an exten
sile phlebitis with local asospasm
Lumbar gangliome blochs relieved the
asospasm Anticoagulation therapy was in
stituted elevation and lot mosst packs were
applied The Gangrenous tissues slougheal and
healing ensucd The right figure shows the
areas with heuing with only minor loss of
tisslic

·110 Vasospasm THROMBOPHLEBITIS Spism Acute thrombophlebitis in the veins of the legs may cause in irritation of the nerves or the artery accomp inying them This is par ticularly true in Hunters cinal where the ves sels are closely aligned Severe arterı il may result Usually this is relieved by warm moist pachs Occisionally more ridical meas ures ure needed as in the following cuses PHLEBITIS WITHI GANGRENE SECONDARY TO VASOSPASM As mentioned above phlebitis in the legs especially in the femoral veins muy give rise to a severe degree of visospasm At times this may be so severe that superficial gangrenous vre as develop especially in the toes Sometimes it may be difficult to determine whether one is de alıng primarily with an ir teral disease or whether phlebitis is the primary disease The pulses in the feet and the oscillometric readings may be absent To release arterial sp ısm the simplest mcisure is to give nitroglycerin sublimguully the usual dose is 00004 gm Ganglionic blochs rre sometimes used This procedure has the dis advintage that it should not be used if the patient is on antico igulint therapy bec ruse of the danger of deep seated hemorrhage from needle truumi The risk is slight but some serious hemorrhages have been reported Slight degrees of visospasm can be releed bi wirm moist picks These picks also help to clear the lymphatic channels ·113 Case 63 Rauds Syndrome Case 63 Raynauds Syndrome with Gingrene Secondary to Arsenici! Vicdiculion Vote necrotic gangrenous ulcerations on fingers Following cirkel symptuctom linds became pik and warm This 35 year old unmined woman had had bronchial asthma for many years She had been gn en the usual treatment for asthma by her physicians and at times she was free of it but at other times she had severe exacerba tions She heard of a supposed cure for astım? in the form of a secret medicine being dis rensed by physician in a distint state She traveled there and obtained the medicine While she was mkng it her asthma greatly improved Accordingly she obtained a num ber of bottles and returned home She con tinued to the this preparation She soon began to develop periode senere blanching of the fingers associated with numbness and ting ling These episodes of Ravnauds syndrome occurred at first only on chilling or during penoils of emotional tension Later lowever they occurred frequently throughout the day without relationship to cold The numbness and linging incre 15c4] prin interme vers murhed visospasm increased thromboses levelope«l in the cligital arteris Accrotic al ceritons of the fingers tlm Impex She was admitted to the liospital Tlie left figure is a lack of lioth hands Note the necrotic gangrenous ulctritions on scyer il fingers The riglit figure is 7 VIC* of batlı lirads following anul sympathectomy Some im provement in rile 18c of the visosp 15:11 oc curred The blach nccrotic ulis liuc localized An an llysis of thus secret medicine proyed it to be roulers solution wluch contains arsenic Thic disease in question w us arsenic poisoning with sccre peripheral neuritis sic ondary visospasm and thromboses of the medium sized vessels ·112 Vasospasm Case 62 Gangrene of the Toes Secondary to Phlebitis with Vasospasm As in Case 61 this 46 year old housewife when first seen had gangrenous areas of her toes It was very difficult to determine whether or not the disease was primarily an arterial one Sublingual administration of nitroglycerin resulted in a return of the pulses ind oscillo metric readings She was treated with antı conguinnt therapy elevation of the feet and hert upplied to the abdomen She made an un cientful recovery without any major loss of tissue The black necrotic arers of the toes proved to be a g ingrene only of the skin When this sloughed good healing was ob tuned As seen in the illustration the dorsal aspect of the toes shows gangrenous blebs on toes 1 2 3 und 4 CIUSC PERIPHERAL NEURITIS This condition may be due to erogenous diphthern often cause i polyneuritis Per toxins such as alcohol hervy metals such as arteritis nodosa (polyingitis) is a common arsenic lead mercury copper gold silver While paresthesiz numbness ind drugs such as emetine isoniazid and chemi muscular purnlysis may be the most promi cals such as nitrobenzol It may be due to nent features vasomotor changes are ieri deficiency states such as beri beri or pellagra common In some such as C250 63 they are The toremias of infectious diseases such as the major factors ·115 Case 65 Ergotamine Poisoning Case 61 (continued) tomy was performed immedirtely The patient was placed on an oscillating bed reflex heat was used across the abdomen in the form of a heating pad one half hour on one half hour of Copalescence was slow but steady She was discharged one month after admission having recovered her major circulation and having lost only a small amount of tissue in the toes All pulses returned The accompanying photographs were taken durmg the reconen stage one week after admission The show spots of necrotic skin Errlier in the course of the disease the toes were cy anotic Two weeks after these pictures the feet were com pletel healed The left figure shons the dorsum of the foot and toes Purplish areas of necrosis are pres ent over the dorsum of the foot and tocs The night figure is a veu of the plantar surface A large purple are i is present over the metatarsal joints and the large 100 Case 65 Ergotamine Poisoning This middle aged building superintendent had suffered from migraine for many years He had polycythemia He had taken er got imine tartrate at frequent intervals This had afected his headaches favorably For the two vecks pnor to admission he had taken un usually large doses Gangrene developed in the right fourth toe The accompanying photograph was taken It is a closc up of the toes and shows a black area of gangrene surrounded by red pre gangrenous tissue The foot was cold the asospasm was severe Treatment consisted of withdrawal of the ergotamine reflex heat applied to the groun the use of an oscillating bed and walking for increasing distances hourly during the day time Healing took place without difficulty - ·114 Vasospasm ERGOT POISONING Medıcıl history is replete with epidemics of ergot poisoning caused by the ingestion of rye bread made with grun contımınated by the fungus ergot This was common in medı eval middle eastern Europe but several ye irs ngo such an outbreak occurred in a small town in France Lewis performed a series of experiments using ergot derivatives In man single experi mental doses (02 to 05 mg of ergotamine or of ergotoxine) gaven intr uvenously caused gıddiness pressure in the head and tiredness The skin of the face hands and feet becime cymnotic for as long as 48 hours und profound rises in blood pressure occurred Experiments with roosters have shown that by feeding with infected grun or by daily intra muscular injections of ergotovine (01 mg) complete stagnation of blood in the comb cin be easily produced and muntuned the result of continuous arterial spasm The stagnation leads to stasis The vessels are damaged and thrombosis follows Ergotism is rare today except following the misuse of medications is in the cise his tories below 02 mg Case 64 Aute Ergot Poisoning with Gangrene of the Toes V MW * This 39 year old woman thought that she was pregnant She attempted to produce in abortion by taking fluid extract of ergot She became confused about the dosage instead of taking four drops at a time she took four tea spoonsful In a period of 36 hours she con sumed 24 ml Both legs became extremely cold punful and later numb On admission to the hospital she was pulseless from the waist down Oscillometric readings were zero up to the groms Early gangrene had de cloped in the toes of the left foot A lumbar sympathec

·117
Case 66 Cryoglobulinemia
B
А
-),
A B C Loss of terminal phalanges (Brown
pigment is result of potassium permangannte
soahs not to be confused with lesions)
D
D Loss of tıp of nose und
ear lobes

·116 Vasospasm CRYOGLOBULINEMIA In certuin disense states abnormal proteins are formed wluch precipitate when cooled slightly below body temperature These pre cipitations occur most commonly in the acral parts where the temperature is lowest namely the tips of the fingers toes eus and nose The precipitate plugs small vessels and le ids to necrosis of the tissues supplied These cold precipitable proteins have been found in patients with multiple myeloma lymphomas of all types and various leukemias Case 66 Cryoglobulinemia This 50 year old white male railu zy clerk had developed blanching of the fingers toes nose and ears some four yeurs prior to admis sion to the hospital Gangrenous areas had developed on the tips of these are is and he had lost tissue on all the surfaces Study in the hospital showed him to have multiple mye lomn Two to four grums of cold precipitable spontaneously crystallızıng protein were found in his blood This case wis reported by Barr Render and Wheeler The upper left figure is a photograph of the dorsum of the hands showing the ulcerating amputation stumps of all digits The upper right figure is a veu of the palmar surfaces of the hands The broun pg ment is the result of soils with potassium per minganate and should not be confused with the lesions The lower left figure is a view of the p? tients feet showing ulcerating uputation stumps of toes The lower right figure is a view of the p? tients head showing a healed ulcer on the tip of the nose and scalloped edges of the eurs secondary to gingrene ·119 Case 67 Sudek s Atrophy Case 67 Sudeks Atrophy (Traumatic Rcfer Vasospastic Dystrophy with Ostcoporosis following Fracture and Avıllary Vein Thrombosis) This elderly ships captain fell on the brudge of his slup during a storm He suffered a fricture of the right humerus The arm was placed in 7 cast Axillan vern thrombosis ze sulted This wis unrecognized for several sechs The arm became edematous and pain ful he did not exercise it the muscles became swollen and taut Vasospasm was severe Radial and ulnar pulses could not be obtained unless the patient was warmed or sublingual nitrogl,cerin was given As time went on the fingers of the hand became thickened and im mobile ray showed marked osteoporosis Treatment consisted of I cortisone to combat the causalgic pain 2 reflex heat 3 physio therapy in the form of gentle missile and Warm whirlpool baths of active excrcise lom provement was rapid Anticoagulants were also administered to present extension of the thrombus they rere munt uned until he was back to full duty The photograph slous 1 view of both hands Note the swollen shiny right frnd fingers and arm Closely related to this disorder arc crush ing or tearing injuries to tlic land in such cases the vasomotor disturbance lends to cold hand rather than a surm one Raynuuds phenomena ue common complications ·118 Vasospasm CAUSALGIA, SUDEK'S ATROPHY The most frequent cause of this malady is in injury to a peripheral nerve without did ing it The median or sciatic nerves are com monly involved but it may be the small nerve endings at the tip of a digit Pain may develop within a week of injury and gradually increase in intensity It often re sults from the use of a cast for a minor or chip fracture It is burning in character and asso ciated with extreme tenderness of the uren of distribution of the affected nerve The prin is superficial and is elicited by slight contact by friction by warmth or by cold It may be so easily provoked and so severe that the patient guards lus irm or leg closely The pan is in tractable and lasts for miny months or may even be permanent if not trented Cortisone may provide some relief The shin may be pink and warm or cold cyanotic, and wet with sweit It becomes shiny Fingers lose their wrinkles The nails frequently stop growing and become brittle I ray studies shon progressive osteoporosis Treatment consists of incre used activity physiotherapy massage weight bearing This must be pursued even if increased pun results temporarily If the reluctance of the patient can be overcome the results ire usually good ·121 Case 69 Raynaud s Syndrome RHEUMATOID ARTHRITIS AND COLLACCA DISCASES All of the collagen diseases and related rheumatic fever) may dumage the peripher il pathologic states (peruuteritis nodosa derma vessels Rayuzuds phenomenr recur coni tomyositis scleroderma lupus erythematosus monly in these conditions Case 69 Raynaud s Syndrome Secondary to Rheumatoid Arthritis 1 www Lille Vote tense shiny skin and canotic fingers Note spindle shaped pale sclerodactylic fingers This 37 year old coal miner had suffered many injuries to his hands He developed painful white cold fingers The skin of the digits became thick and taut the joints be came spindle shapes and the night ulnar artery was found to be occluded Eosinophi liz was persistent and ranged from 6 to 11 per cent A very thorough study in the hos pital led to the establishment of the diagnosis as rheumatord arthritis חנן The left illustration is a front view of the patient with ins hands placed on bus abdo men Note the spindle shaped pile sclero dactylıc fingers The nght illustration is a close of the palmar surfaces of the hands Note thic tense shiny skın Tlic terminal No 5 right phalın had been lost in un accident some ( irs previously Varked improsement in all symptoms was obtained with steroid therapy ·120 Vasospasıl Case 68 Persistent Vasospastic Phenomena follow ang Trauma Dorsal view Note mottling of skin with cv inosis of fingertips This US Army privite while in combat suffered a hand injury from a grenade The fourth finger was amputated When seen by us three years after the explosion the hand showed extreme vasospasm The pilm of the hand is shown in the left photograph and the dorsum at the right The radial and uln ir pulses were very feeble The hand was cold moist and purple When nitroglycerin was administered sublingually the pulses became augmented indicating that the underlying mechanism was not an organic occlusive dis ense but rather on the basis of muscular con triction of the vessel walls The patient was instructed to wod ull fictors that might in duce v asospism nimel I tobacco 2 chilling of the body 3 chilling of the hund He was advised to wear ? glove in any cold werther and he was instructed to take a warm drink when his fingers became blanched and if this did not give instant relief to the i nitrogly cenin tablet under his tongue With the pas sige of time the symptoms gradually subsided Both photographs shou mottling of the skin with ci inosis of the fingertips Of interest is the fact that the brother of this patient u is later shot in the hand and developed the same syndrome ·123 Summary SUMMARY Vasospasm in the peripheral vessels has been discussed Primary diseases are Ray nauds disense 1c olyanosis and Invedo reticu larus Case historics were cited in which the clinical manifestations and therapy were dis cussed Secondary Raynaud s phenomena my occur in the course of many diseases affecting blood vessels They include the following scleroderna thromboangutis obliterans ather osclerosis obliterins neuroi iscuſir syndromes of the shoulder gordic thrombophlebitis pril liry vein thrombosis (rostluste perilo and chilblains peripheral neuritis crgot poisoning and ergotimine poisoning inololuline mi causalg. Suleks atrophs and traumatic sospastic phenomeni rheumitord arthritis and perrurteritis nodosa Ciscs illustrating these conditions hue ben presented BIBLIOGRAPHY Allen ET Barker NW and lines E4 Jr Peripheral I ascular Diseases 2nd ed Philadelphia WB Saunders Co 1955 Wright Is Vascular Diseases in Chnical Practice 2nd ed Chucamo Year Book Publ 1952 Varde Vand Sayen A The prinary influence of basal vascular tone on the development of post Ocelusi e collateral cueul tron and in selecting patients for sympathectomy Am J V Sc 209 478 1945 Foley 1 T VeDevitt E Tulloch JA Tunis VI and Wnelit, 1 S Studies of vasopisu The use of glyceryl trinitrite as a dualnostic test of periplural pulses Circulation 7 647 19,3 Bart D Reader and Wlaceler C Cryoglobu linemia Ann Int Med 31 6 1920 Estes ] [ Voltm Concepts of Cardio Vascular Disease New Yorh Anier Jient Assoc los 19,0 ·122 Visospasm PERIARTERITIS NODOSA Vasospasm is frequently present in peri arteritis nodosa it is often the presenting sign of the disease in the early stages it may be confused with thromboingutis obliter ins primary Raynauds dise ise or Raynuuds phe nomena secondary to other viscular dise ises Case 70 Periarteritis Nodos? This patient is ? middle aged salesman His illness commenced two months previous to the time these photographs were taken He noticed a sudden numbness in his left hand During the next several days two fingers be came blanched and cold The other limbs rapidly showed sigus of arterial insufficiency There was a leukocytosis with eosinophilia up to 10 per cent Peripheral neuritis developed probably due to ischemia of the nenes Thrombosis of the large vessels soon followed The upper left photograph shows black gingrene of the toes with sloughing of tissues The upper right photograph is 1 view of the plantar surfaces of the feet and shows eu tensive gingrene extending to the midportion of the left foot The lower photograph is ? view of the hands showing extreme pallor The left index finger is gangrenous and tissue is sloughed from the tip ·ur Aneurysm An arterial aneurysm in its primar form 2 Syplulitic Aneurysms Aortitis 1 mm is simply an abnormal dilatation of an artery festation of inadequ itely treated sypiulis ne Trauma may injure the vessel 7) The pres curs most often in the ascendiu aorta ind the sure of the circulating blood then causes the nortic arch less often in the descending and weakened wall to dilate The dilatation may be the abulominal north and more rarely in the diffuse or saccular The sac consists of the ves extremities Tliese zneurysms muy boc fusi sels wall This is a true aneurysm form or sacculir In other instances the arterial wall is split 3 Atherosclerotic Aneurysms Aneurysm or destroyed in part or completely and the due to atherosclerosis is nos encountered with contiguous structures for a sac lihe enclosure increasing frequency Tlus is duc pnmur through which the blood circulates This is to the agin, of the population The meciul called o false“ aneurysm which usually de coats of arteries affected by therosclerosis velops as a result of a fracture of a calcific may rupture This may occur at an are of plaque calcific de posit or plaque The form of dulita The inner wall of an aneurysm may be tron of the artery depends upon the local con lined with laminated blood clots thereby caus dition of the blood vessel the contiguous ing a reduction of the pulsations structures the tension in the vessel and the Dissecting ancurysms are usually on the degree of successful repur Mild trauma of a basis of medun necrosis but may be of vessel affected by atherosclerosis is a frequent atherosclerotic origio The orginal splitting precipitating cause of aneurysms Common or of the media may occur without any communi amples of this are saccular aneurysms occur cation with the lumen At some time later a ring in the popliteal artery tear of the intima occurs Dissection progresses Atherosclerosis with mechial necrosis is the betueen the layers in either direction Less most common cause of dissecting aneurysms commonly a plaque splits and the medial dis Thrombosis of the arter) as a frequent compli section extends from there cation and at times may produce complete oc 1 Congenital Aneurysms In these the clusion Rupture of an aneurysm of a uryc medial coat may be undeveloped or absent artery or m a critical location may result in dilatation may occur early in life These aneu death Gangrene my result from incury sin Tysms are often found intracranially in the of a periphưral vessel Usurlly this is associ internal carotid artery or in the circle of Wales ated with occlusive thrombosis of the incu Rupture usually causes fatal cerebral hemor rage although minor leakage may give ad Tysm or with embol which arise from a mother clot in the ancurysm and move peripherally to Vance woning block smaller arteries Early diagnostic cri 125

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·Arteriovenous Anastomosis As the result of an arterios enous fistula short circuting occurs in which a portion of the blood returns to the heart without having accomplished its function of nourishung tho tissues If these channels are of sufficient total size so that large amounts of blood may be shunted by this short circuit nutrition in the distal part may be inadequate for the life of the tissues Gangrene may ensue This mas also result in cardiac hypertrophy and with large fistulas in heart failure In small fistulas this does not occur Arteriovenous anastomosis 127 nunt in that ifter ercision now anastomoses dc clop with extension of the process usually proximal Thouglı pathologically they do not hue the appearance of a mulignancy they may ultimately result in the loss of the part by imputation and in some instances in the loss of hle 2 Traumatic Gunshot or stab wounds arc common fruses of arterios enous fistulas but they may be cused bs crushing injuries as well 3 Secondary to Valignancy Valignancy mu werhen the walls of 1 blood vessel l» direct invasion resulting in an arteriovenous fistula 4 Secondary to Bacterial Infection of thic Surrounding Tissues such anh ction mı in vade the walls of an artery and rem prouduc ing an arteriovenous fistula 5 Secondary to Fungous Infections Such infections may act similarly may be 1 Congenital Congenital anastomoses are much more common than has previously been believed the possibility of arteriovenous con nections should be considered when there are congenital vascular anomalies such as caver nous hemangiomas suddenly appeanng" var cose veins and some of the port wine and other vascular skin anomalies Some congenital arteriovenous connections are localls malig ·126 teria are the physical findings of a pulsating mass or the roentgenographic appearince of enlarged vessels often with calcified walls Pun may occur especially if there is erosion of bone or pressure on nenes Bruts can fre quently be heard over the aneurysm but can also bc heard over any narrow ed or roughened artery 4 Mycotic Aneurysms The wall of the north or of other arteries may be weakened by suppuritne processes secondary to actinomy cosis tuberculosis subcute bacterial endo carditis septicemia pneumonia typhoid fer er or other infectious diseases A looni in fection around a major vessel muy so weiken it is to lead to an ineurysm or to ripture Aneurysm Aneurysms occur most often whicre there is marked stress and strun on the artenal walls, es ncar joints in the extremities 5 Traumatic Aneurysms May be of the true" or "false variety An injury to an arten may cause its immediate or later dilatation This development may be delayed due to the pressure of the contiguous structures or be cause of a concomitant hematoma 6 Embolic Aneurysms An embolus inay enlarge an artery ind cause i wcikening of the intimal ind medal layers with secondary aneurysmal dilatation 7 Idiopathic Aneurysms In certam in st inces the true ciuse for the incurysm cın not be ascert uned ARTERIOVENOUS ANASTOMOSIS (TISTULA) Arteriovenous anastomosis is an abnormal communication between an artery and a vein This may be congenital or acquired The com munication may be 1 Direct such as follows a stab or gun shot wound 2 Through a siccular ineurysm involving primarily one vessel 3 By in abnormil dilatation of the walls of the several vessels involved 4 By arteries and veins opening into con tiguous structures Congenital anastomoses are usually multi ple ind my number in the thousands The following signs and symptoms may in dicite the presence of an arteriovenous inas tomosis 1 Enlargement of a limb or arei of the body surface 2 Local increase in perspiration and growth of hair 3 Increased local temperature 4 Rubor of the affected area 5 Unusual prominence of veins 6 An ludible bruit over the affected urea occasionally a thrill may be felt In congenital or small nastomoses bruts are frequently absent 7 Increased ovygenation of venous blood proumal to that ireTlus cruscs thic venous blood to be brighter red than the blood from corresponding normal seins Such a compinson constitutes a simple useful dignostic test Studies for ovygen unsaturation usually con firm this finding 8 Cudic insufficiency with enlarge ment of the heart is a frequent com plication 9 The pulse may be slowed by pressure applied to the affected area 10 Arteriographic studies may show the abnormal communication Il Birth murhs hemangiomas and related inscular lesions may be associated ·129 Case 71 Abdominal Aortic Ancurysm In the accompanying figures note the con trast media in the aorta in the two films taken one second apart The colon is partly filled with barium Accordingly he was prepared for opera tion The aneurysm was resected An aneu ism of the abdominal aorta below the renal artenes (such as in this case) is almost always arteriosclerotic Thoracic aneurysms were formerly most frequently syphilitic but as a result of the improvement in antisyphilitic therapy and the aging of the population this is no longer true This aneurysm was replaced by an aortic homograft extending from 3 cm below the renal artenes to each common alınc artery The patient withstood the procedure well Pulses were obtainable in both femoral arteries immediately following the operation and also in the right foot Pulses did not re tum to the left foot until the following day The wound healed well There was postoper tive distention He was kept in bed for 14 duys At the end of that time lic was progres snely mobilized and at the end of the tuents fourth day was discharged from the hospital Helias been follow col for three years I his reg uned laus strength feels well and fit llis pulses are strong in all normal locations Watliout surgical inton ention the proc nosis of this patient was hopeless In a studs of patients with alxdoinın al aortic immun sms seen at The New York Hospital it is found that fewer thin 5 per cent stinni ed a fisever period of unoperited DeBikey has shown liat following surgery the longevity is about the same as the normal for the age group Until the development of artery banks the problın of the abclomin al zortic cum \is of academic interest onls The successful use of the grift in this patient shows the possibilities of surgery in this condition which ind for merly been considered hopeless Today duc ron and nylon grafts line lugels replaced homografts ·128 Aneurysm Case 71 Abdominal Aortic Aneurysm Contr ist media in aneurysm of aorta colon partly filled with barium Mr A B (The New York Hospital #744 16-1) was a 71 year old private chauffeur who had retired to live in Florida In June 1956 he developed dyspepsin He consulted a physı cian who prescribed alkalies His symptoms improved Tays were taken at that time which showed a mass pressing against the stomach This was thought to be an aortic aneurysm and he was referred for vascular consultation General examination disclosed that the patient was a vigorous man The abnormal findings were largely confined to the ab domen At the level of the umbilicus there was a firm pulsatile mass measuring 10 cm width and 11 cm in length it was slightly tender to pressure Over this mass a rough systolic bruit could be heard This bruit could be traced up into the chest and u z synchro nous with the systole of the heart Also over the area of the aortic valve there was a similar rough systolic bruit Both femoral pulses were strong as were the dorsalis pedis and pos terior tabral pulses Oscillometric readings were normal blood pressure in the right arm was 172/96 Gastrointestinal series showed extrinsic pressure with displacement of the stomach duodenum and small bowel due to an en larged calcified abdominal aortic aneurysm An aortogram was performed under general anesthesia This showed a large saccular type of aneurysm מן ·131 Case 72 Dessecting Aneurysm of the Aort? There was no nausea vomiting or diarrhea the itcr, down through the chest into the abdomin il norta and ending at its bifurcation There were no bloody or tarry stools He was admitted to the hospital v ambulance On The pericidium contuned about 700 ml of admission to the hospital 15 mg of morphine blool Extensiic atherosclerosis of the 7 was administered for the pain During the dominal aorti is found together with ather ni bt, on the occasions he had some nausea omatous formations in the coronary Hissels occlusion of the interior circumfer coronary and vomiting but slept for ses eral hours The blood pressure and pulse were well urten and 1 healed myocardil infirction in maintained Physical examination showed thic anterior literal will that he was a well developed and nourished COVVENT In retrospect one would say acutels all man who was apprehensate per that this mus basic dise ise ** as hypertension of unknown (Huse This led to extensive spinng freely and in acute pun but alert and onented No cyanosis or pallor w is noted ntherosclerosis of the aorti ind coronary 16 His pupils were round regular equal and teries A throibiotic occlusion hid descloped Teicted to light and accommodation Vedial at the site of an atherosclerotic plaque in ? and just below the angle of the left scipula Jirge coronır, utery causing 1 myocardiul an area of dullness to percussion and bron infarction Vedul degeneration had occurred in the aort i dissection from or into an athero chial breathing was noticed No rales were heard Retrosternal dullness in the upper sclerotic plaque had led to 1 splitting of the sternal area was found but over all cardiac layers of the aorta in the region of the medial dullaess was not increased A suggestive para degenertion This in turn extended the dis doncal pulse was noted The second aortic section down the full length of the nort1 A sound was greater than the sccond pulmonic rupture into the pericardium from the original sound The rhythm of the heart was regul ir site of dissection had also occurred The des and the sounds were somewhat overshadowed section may hoc been progressing silently for by a loud to and fro friction rub heard over 1 long time but cxtended with cntıcıl splittino the whole pericardium The nech veins were occurring on the day before death when the not distended the liver and spleen were not patient experienced the severe pain in his chest felt and the peripheral pulses and femoral pulses were palpable ind equal Neurolo,ic The differential diagnosis for consideration His a fresh myocardial infarction In such a examination was normal During the night, in addition to the pen case one would not expect the blood pressure cardial friction rub a high pitched diastolic to have been maintained The finding of car murmur was heard at the base of the heart drac tamponade with ? hemopericirdium might have been ascribed to the anticoagulant Peripheral pulses were still palpable and of good quality No venous distention occurred therapy This however was not the case Death occurred precipitously Anticoagul ints were administered in an clfort Postmortem examination was conducted to prevent new thrombus formation in the The illustration shows the extensive dissecting diseased coronary tree This therapy does not anuursm that was found extending from the appe ir to interrupt the atheromatous process which sinus of Valsalva rupturing into the pen may escntually occlude the coro Cardium ind dissecting the medial coat of nary vessels completely in the absence of a thrombus ·130 Aneurysm Case 72 Dissecting Aneurysm of the Aorta Patient E AI The New York Hospital #740148 was 1 54 vear old actor The dis secting aneurysm of the horta is shown in the accompanying figure In May 1953 he suffered an anterior lateral myocardial inftrction For one year prior to this he had been known to have had high blood pressure At the time of his infarction his blood pressure fell to normotensive levels He was in the hospital for a period of three weeks on inti coagulant therapy He was then ambulated His blood pressure gradually rose and within a period of six weeks returned to the pre infarction levels During the next two years the blood pressure ringed from a high of 190/110 to a low of 160/90 He was continued on long term dicumarol therapy His pro thrombin time 125 maintained between 24 and 32 seconds on in average duly dose of 75 mg of dicumarol During two years of ob sertation he showed no untoward effects from the anticoagulant administration His blood cholesterol level in October 1955 was 250 mg per cent Following a diet low in animal fat it was found to be 192 mg per cent in Virch 1956 His serology was negative his hemo gram was normal \ rays of the gallbladder showed normal function Surpasıl and Rau dixin were used in an attempt to control his blood pressure However even small doses of these drugs gave rise to nas al stuffiness and 1 regular dose schedule was not followed On May 30 1956 three days prior to his death his prothrombın time was 28 seconds with a control of 14 seconds On that day he had no complaints During the early morning hours of June 2 he was awakened by a severe bifrontal herdache which was not relieved by aspirin He finally fell asleep and on arising remained well until shortly after lunch when a sudden severe nonradiating persistent substernal pain developed Weakness perspi ration and marked apprehension with poorly localızed abdominal discomfort followed

·Case 73 Aneurysm of Innominate Artery
133
Heart dullness percussed out
on chest colored red Purplish
area on cheek indicates where
sweating occurs white area ab
sence of su cating Fingers of
right hand show clubbing
Constricted pupil on right clitud pupil on
left and absence of su cating on right indicate
loss of sympathetic nerve connection
Angiocardiogram shows
opaque dye in the left outflow
tract of heart and in aneurysm
of innominate artery

·132 Aneurysm Case 73 Aneurysm of Innominato Artery The diagnosis is meurysm of the innomi mute urtery due to syphilis This 50 year old man hd hind 1 primin chancre on his penis 20 years before His blood and spinal fluid Wassermann were still positive Blood pressure was 210/92 A soft lugh pitched du stolic murmur was heard to the left of the sternum There w is great en largciment of the left ventricle The right pupil Wis simaller than the left and sweating was absent on the right side of the face indicating loss of function of the sympathetic nerve fibers m thus rci The pulses and oscillometric readings in the right arm were very marhedly reduced Clubbing of the fingers of the night Irind developed The upper left figure shows the wei of the heart dullness percussed out on the chest colored with red The chicchs have been covered with starch paste and iodine The purplish nrer indic ites where sweating oc Curs the white are? absence of sucating Note that over the right side of the face sweating hus not occurred Fingers of the right lund shok mırhed clubbing The upper right figure shows the con stricted pupil on the right and the dilated pupil on the left and absence of suciting on the right The lack of swerting plus the di lated pupil tre indicative of the loss of sympathetic nerve action The lower figure is an angiocardiogram It shows the opique dic in the left outflow tract of the heart and in the incursin of the innominate urtery PROCNOSIS Without therpy thus aneurysm could be expected to enlurge progressively Eventually it might rupture or crode through the adjacent structures such as the bronchus the csophagus the ribs or the spinal coluinn In such cases antıluetic therapy must be quen very cautiously to present an acute influn mntor rection in the ancurysm Small doses of pemcıllın irc indıcated with 7 gradu il in cre ise in the size of the dose over i period of ses cral inonths

·Case 74 Arteriovenous Aneurysm
135
Aote atrophy of right leg
Large tumor formation over
right lumbır and thoracic 77015
posteriorly
Esecs
Aortogram showing anasto
mosts of vessels throughout pel
vic lumbar and lower thoracic
Five years later Note increasing size of tumor
urers

·134 Aneurysm Case 74 Arteriovenous Aneurysm, Congenital At the age of five this boy was found to have a lump in his right buttoch The follow ing year it was noticed that the right leg was warmer than the left leg A bruit was heard near the spine A dingnosis of arteriovenous anastomosis was made and the internal line and obturator arteries were ligated The bruit disappeared temporırily but returned 1 year Inter This is characteristic of congenital interio venous anastomoses Usually there are miny hundreds of tiny connections between the arteries and the veins One of these grdually increuses in size until it becomes aneurysmal It signs and symptoms which may be attacked surgically Removing the ineu rysm then puts increased hemostatic pressure on one or more of the remaining anastomoses One or more these in time usually develop into 2 large fistula For this reason multiple slirgical procedures ire often performed in such patients Surgery is usually not perma nentl successful but it may be advisable to attempt it in order to relieve temporarily the strain on the heart The upper left photograph was taken when this man wis 21 years of age Note the utrophy of the right leg which is located below the site of aneurysmal formation in the irterial tree The skin is tight ind shin The muscles we finbby und shrunken Edemi is present over the fo which is larger than the opposite foot Pigment de posit is present up Over the shins The upper right photograph shows the large tumor formation over the right lumbar ind thoracic areas posterior a large bruit is heard over this rrez Marhed pulsation ein be felt The lower left figure represents in norto grim made by insertion of 1 catheter the right femoral and ilmc uteries into the ab dominal aorta Contrast medium was then in jected Note the great in istomosis of vessels present throughout the pelvis lumbar and lower thoracic are? The lower right photograph was taken five years later at the age of 26 Note the in creasing size of the tumor Further surgery in this patient w is considered to be impos sible without domage to the renal arteries II is a perminent cripple with poor pectancy ur gives rise to life

·137
Case 75 Arteriovenous Anastomosis
Dorsal view
palmar vies and close up of enlarged
Tarix of fourth finger

·136
Aneurysm
Case 75 Artcriovenous Anastomosis, Congenital
This case is a 24 year old housewife From
the age of two prominent veins were noticed
in her right hand As she grew the right hand
became larger than the left She also noticed
that the temperature was warmer She was
first seen by us at the age of 17 At that time
a large pulsation was noticed in the palm of
the hand A loud bruit was heard Surgery
was performed and the arteriovenous anas
tomosis was excised Subsequently new anas
tomoses have made their appearance and
several surgical procedures have been carried
out but in this
is usual in genital
arteriovenous anastomosis there are probably
very many scattered small channels between
arterioles and venules Under pressure these
develop into large fistulas At present the
patient has a loud continuous murmur at the
wrist and another at the base of finger num
ber five
The upper left photograph is a close up
of the back of the hand The upper right
photograph shows the palmar surface indici
ting dilated veins The lower photograph is
1 close up of the ring finger enlarged vary
over which is heard a loud hum

·139
Case 76 Arteriovenous Aneurysm
B
A
с
D
E
Distended seins and hypertrophy of left leg B Vote the large sack of seins A loud brunt
as heard here Anrtogram showing "corkscrew" iliac artery D and E he month follow
p Notice disappearance of dulated veins and return of leg to normal size

·138 Aneurysm Case 76 Arteriovenous Ancurysm Truumatic Thirty years ago this 60 yeır old man was accidentally shot with 2 rifle bullet through the nbdomen The bullet actually entered the right lower quadrant It pierced just above the bladder and come out in the left groin In its course it nicked the left femoral artery und vein An arteriovenous communication developed Through the yeurs massive distention of the veins occurred in the left leg which be cime su ollen and heavy This excessive ab normal shunting of the blood into the systemic circulation which was of no physiologic use grudunlly put a strun on the heart Left ven triculır hypertrophy followed and after many years decompensation occurred The upper left figure (A) shows the greatly distended veins over the left thigh and leg Note the thickness of this leg as compzred with the right leg The next photograph (B) is a close up of the groin A large ste of veins is present here Over this area z large bruit is heard and a thrill is felt The next photograph (C) is that of an nortogrım Note the widely distended twisting irtery Surgery is performed during which thes large arterial segment was removed and the veins druning into it were ligated Follow ing surgery although no pulse was present in the femoral area of the groin strong popliteal and foot pulses were present indicating that excellent collateral flow was present The next two photographs (D and E) were tiken five months postoperatively Note the disappearince of the large dilated veins and the return of the leg to i normal size The close up of the groin shows the surgical inci sions A small stitch abscess remuns All the dılated veins have disappeared in contrast to the congenital arteriovenous fistula 1 traumatic fistul z is apt to be single and when once sic cessfully removed it will not return ·6 Diseases of the Small Vessels IN PEASED FRAGILITY OF VESSELS 1 Infectious purpura due to (a) Bacteria (b) Viruses and other micro organisers 2 Touc purpura due to (a) Arsenic (b) Phosphorus (c) Phenolphthalein (d) fleparn and related sub stances (e) Coumarin derivatives und zu lated substances (f) Tenom (g) Other tous 3 Purpura due to autaminosis (a) Lack of vitamin C (scun) (b) Lack of vitamin (c) Other vitamin deficiency 4 Purpura, secondary to increased se nous pres ure 5 Menstrual purpura INCREASE PERMEABILITY OF SSLLS 9 Urticirua and angront notic edle mi 10 Sensitivity to physical agents (a) Mechanim (b) Cold (c) llent 11 Jlematogenic purpura due to (a) Thrombocytopenia (b) Leulemia (c) A plastic anemia (a) Cranulocytopeni (e) Disturbances of clothing mechanism 12 Deficiency of blood clotting factors 13 Local inflammation 14 Inaphylactic slioch 15 Traumatic shock 16 Bums 17 Frostbite 6 Semle porpura 7 Idiopathic purpura (a) Henoch s purpura (b) Schoenleins purpura & Allergic purpura \ enclature and deanpuons in this chapter are taken from the Womenclature e id Criteria for Dragno 315 of Diseases of the leart and Blood Vess lo 5th ed New York New York Heart Association Inc 1931 Not only the capillaries but also the finest arterioles and senules are included under the term small cssels As the blood passes through the capillin network there is a constant interchange of certain of its constituents with the tisstic fluids In conditions leading to increased prcs sure within the lumen or ta damage to the capillary walls additional scrum and formed elements may escape when there is an extra Vasation of cells into the skin or mucous membranes the term “petechiae" is used for 141

·No text on this page.

·143 Increased Permeability of Vessels tumors or prolonged dependency of the legs as in long trips by ar rail or automobile (especially while weung constrictive gre ments such as girlles) Garments mus be re sponsible for increased enous pressure with secondary hemorrhages Such purpuric ires are usually small in size and located about the feet and ankles They may also be found at the site of actual compression of the thighs 5 Menstrual Purpura This is a rare phenomenon of unknown cause it may occur in any part of the skin of the body except the face 6 Senile Purpura Purpura occurs in the elderly wathout adequate etiologic explına tron although malnutrition must always be considered With the achlorhydria which is common to the aged the absorption of vitamin с inny be interfered with 7 Idiopathuc Purpura (1) JENOCIIS PURPURA This is 1 recur runt mully chiricterized by purpuri ire is which may ulcerate The skin and mucous membranes are involved Attacks of icut ab dominal pun ma result from inte stmul lesions (b) SCHOENLEINS PURPURA This is pur pur ith joit manifestations The diagnosis depends upon purpuri appe inng in the skin and associated with puns in the joints This may be due to hemorrhinges in the joint cip sules It is frequently classified as one of the rheumatoid group of dise iscs 8 Allergic Purpura This form of pur puri occurs with or without thrombocy to peni? INCREASED PERVEABILITY OF VESSELS Normally the capillars walls retain the (1) Vechincal irritation (scratching pres solids of the blood and certain dissolved and sure friction) suspended matenal of high molecular weight (b) Cold (allergic release of lustamine) The capillary wall acts as an osmotic mem (c) Hert (thermal damage to capillary brape allowing fluids and electrolytes to flox walls) freek in accordance with physical lalis Un 11 Hematogenic Purpura This is not a der certain conditions the capillary wall may primary disease of the minute blood vessels be changed so as to allow protein and other They are affected by cert un blood conditions constituents to flow through which cause purpura Thc dcfect in at le ist 9 Urticaria and Angioneurotic Edema some of these conditions is a decrease of This s a result of a localized capillary dila thrombocytes It is assumed that small open tion and injury and edema of tissue spaces ings are constantly being produced in the due to the action of histamine substances walls of camllaries due to trauma infection This may be secondary to a generalized sen or loss of intercellular cement substince sitivity state or to local irritation as outlined These holes are normally quickly plugged by belon blood platelets and fibrin with other cellular 10 Sensitivity to Physical Agents "This constatuents If there is a defect in their num results in local swelling due to extravasation ber or chemotaxis the holes are not suf of fluid into the tissue spaces of the skin ficiently plugged and hemorrhage ensues which appears pale or red and may be clue to The commoner causative conditions are ·142 minute hemorrhages 2 mm or less in diume ter and which we often multiple ind “pur pur for larger hemorrhages Normally tiny cutaneous hemorrhages occur ifter even? Diseases of the Small Vessels brief constriction of a limb These are proba bly due to increased capillary pressure plus the added fictor of movem of the cells of the capillary walls INCREASED FRAGILITY OF VESSELS 1 Infectious Purpura (2) DUE TO BAC (f) Vevov Cert un types of snake and TERIA Petechine are characteristic of buc insect Venom are touc to capillurics (throm teicmius and septicemi is notably in subacute bogenic and hemolytic) bacterul endocarditis Any overu helming (g) OTHER Towns bacterin) infection may give rise to capı]] ary 3 Purpurs due to Autaminosis damage which is reflected clinically by the (1) LACK OF VITAMIN C Scurvy due to appearance of hemorrhnges in the skin and lack of utamin C is characterized bs easy mucous membranes of pinpoint size or large bruising and bleeding gums from capillary enough to be called purpur oozing Appirently the defect is in the loss of (b) DUE TO VIRUSES AND OTHER MICRO cement substance from the capillary walls ORGANISMIS Viral or nickettsıl purpuri is themselves Subclinical scurvy mu be detect chincteristic of chickenpox smallpoi înd able only by the capillary fragility test ind many viral infections It is found nearly al confirmed by finding 2 subnormal concentra was in typhus and other forms of rickettsial tion of vitamin C in the blood Circful cum dise ises nation of the skin about the inkles often re 2 Toxic Purpura This may be caused by veils the first evidence of scurv or of various poisons such is those listed below increased venous pressure This physical find (1) ArsENIC Purpura ma follow the ad ing is frequentis missed ind mu be of reu mmistration of arsphenimine derni ities such value Specifically it is the thermolabile u as Foulers solution tumm C ishich is lacking in scuri (b) ProSPHORUS (b) LACK OF VITAVIV I Lich of ut unin (c) PHENOLPHITHALEIN This drug is found produces a deficiency of prothrombin This in many proprietary Initives muy result in hemorrhage from the cipollaries (d) HEPARIV An overdose of heparin or (c) OTHER VITAVEN DEFICIENCY It is hepırın like substances such as pritol and clumed that utimin P deficienci mn crust treburon will often cause purpuri cipıllary fragilits but this is controversial (c) COUVARI DERIVATIVES AND VITAVITI 4 Purpura Secondary to Increased Ve BLOCKING AGENTS These substances include nous Pressure Increased venous pressure bishydrou coumırın (dicumirol) ethyl bi leads to an incre ise in capillan pressure scoumicette (tromevan) cyclocum rol di Small hemorrhages may result from rupture phenndone and others Slight trauma produces of these sessels Petechnie and purpuri ir purpur in patients receiving significant frequently seen is a result of defective sonous amounts of inticongulant drugs In Over return because of venous valvular defects dosage lrrge hematomas may form mechanical pressure on veins is from peluc

·Case 77 Purpura with Agranulocytosis
115
Purpura of lips oral cavity
and ala nast
Hemitomanel purpur Phle butts un Suns
of lower leg
Large ecchymotic are is

·myeloid or 144 thrombocytopeni? lymphatic leukemia aplastic anemia grinulocy topenia and disturbances of the clotting mechanism such as hypoprothrombinemia Purpuric ure is are also often seen associated with severe liver disease with associated disturbances in the coagulation factors in the blood 12 Deficiency of Blood Clotting Factors A deficiency of such factors is fibrinogen prothrombin Fictor V Fictor VII Fictor VIII Factor Il Factor \ind the Stuart Prower Factor while primarily due to defects in constituents rather than in vessel walls muy result in casy bleeding into the skin These may be congenital hereditary or in some in Diseases of the Small Vessels Stunces acquired A detuled discussion of them is beyond the scope of this volume 13 Local Inflammation A change in cip Jury permerbility is characteristic of inftar mation of all types 14 Anaphylactic Shoch This may be as sociated with #heals or grac urtic inior edemi 15 Trrumatic Shock The picture of shock may be accompimed by the appearance of lirticarul wherls sometimes blisters 16 Burns These may cause missic en dition and loss of fluid into the tissue spices 17 Frostbite This is discussed elsewhere Case 77 Purpura with Agr inulocytosis This elderly woman complained of prins in her joints She consulted a physician who prescribed phenylbut tzone 100 mg to be taken after erch meal for a period of seven dus The womın obt uned a great deal of relief from this medication and decided to continue it without consulting her physician She hept up the drug for a period of six months Suddenly she developed bleeding in her mouth legs and thighs Examination dis closed that the bone marrow had cersed to produce granulocytic cells There was also a complete absence of platelets in peripheral blood sme irs Phlebitis hid developed in the Veins of the legs as well as lurge hematom is ind widesprend ecchymoses Bleeding ind also occurred in the lips in the oral ciuity and about the nose The upper left illustration shows the pur pure of the lips oral cavity and li nasi In the upper right illustrati hem tom ind purpura are shown in the purple and dir red areas Phlebitis is present in the veins of the lower leg The lower illustration shows large ecchymotic areas ·117 Case 79 Subclinical Scurvy Case 79 Subclinic Scurvy - This 30 year old housewife had had very marhedly incre used vasomotor tone since childhood On exps ure to cold blotches of purple discalaration occurred on the skin of the legs and arms The hands became cold pale and moist Tiny ulcers appeared Her diagnosis was lavcdo reticularis which has been discussed in another chapter An addi tional finding was present in her case which contributed to the formation of the ulcers She gave a history of ncver eating any fresh frunt salads or raw food of any kind with the ex ceptwn of mik A Rumpel Leede test was done using the Wright modification This consists of placing blood pressure tourniquet around the arm in the usual manner pumping the pressure up to halfway between systolic and diastolic and leaving it in place for a period of 15 minutes At the end of that time the petechise are counted in two circles cach 1 inch in dume ter The circles are located 2 inchies below the elbow creasc Normally there should be fewer than 10 per circle Ten to twenty is considered marginal and over 20 pathologic While thes is characteristic it is not specific for scurvy In this patient an innumerable number of petechiae developed as shown in the illustra tion showing subclincal scurt terlal ly the capillary fngility test Iier blood vitamin C level was 02 mg per 100 ml the normal is 08 to 12 mg She was given large doses of vitamin C orally and intravenously pamely, 1000 mg per day by both routes The capillir fragility quickly returned to normal the ul cerations healed

·146
Diseases of the Small Vessels
Case 78 Senile Purpuri
This 76 year old man compluned of
purplish spots on the skin of his legs A com
plete erımınation showed no positive findings
that were not compatible with his advanced
age The blood count wis normal Bleeding
time clotting time platelet count blood clot
retruction prothrombin time crpill try fragility
tests were normal The patient was also exam
ined from the point of view of a lesion in his
prostate gland None was found Carcinomi of
the prostate frequently metastasizes to the
bone marrow and may ghe rise to purpura
Circinomi of the prostate also produces ?
proteolytic enzyme which sometimes gives rise
to purpurr and to hem. im In this patient
the diagnosis of senile pu puru is arred at by
the cyclusion of other conditions such as de
fects in his blood clotting mechinism in his
hiematopoictic system or circinom of the
prostite This is a common condition w duch is
rirely a serious problem
The photograph shows senile purpura The
fresh lesions are purple older oncs ire brown
from hemosiderin formation

·149
Case Si Ulcers
II TERTENSI E ISCHIEVIC ULCERS
In some patients with arterial hypertensnc mu become he month agr chica de crotic This
disease the arterioles of the skin become can occur (1en in the presence of strongh
sclerotic and thromboscd Small areas of skin puls iting larger vessels
Case 61 Ilypertensile Ischemic Vleers
1
Large sessotic ulces a los er
thud of tabia
Pinch grafts covering ulur
Tlus patient is a min tl years of age lle
had been known to hase hid lugh blood pres
sure for many years His pressure while under
our observation mnged from 300 to 20
su stolic over 120 to 10 dizstolic All the
peripheral pulses were strong oscillometric
reathnks were normal The left figure shows
the lar e necrotic ulcer that had formed over
the lower shin This was debrided and pinch
Grafts appled as shown in the rivht hgure
Successful healen, was ohtuned The patient
responded very well to Rauwolfin therp llis
blood pressure fell to a rince of 150/90 and
has been maintained in this region for a four
scar period of follow up During this time no
further ulceration has des cloped

·148 Diseases of the Small Vessels Casc 80 Clinical Scurvy < Coalescing petechul rush with extensive hemosiderin for mation from old hemorrhage A small ulcer las forined Wright modification of Rum pel Leede test This 60 veir old woman compluned of ? rash over her lower extremities She gue ? history of having abstuned from all run foods for several ye irs A Rumpel Leede test Wright modification as shown in the right figure gue innumerable petechiae Blood vitamin C level was 03 mg per 100 ml She was given 1000 mg per day of vitamin C orally and injections of 1 similar amount intr uvenousls twice wechly The increased capillary fragility rap idly returned to normal The ish cleared es cept for the hemosiderin deposits which remuned 15 n brown strin The left figure shows ? co zlescing petechiul rish Extensive hemosiderm formation from old liemorrhage is present i small ulcer his formed the right figure shows the Rumpel Lecde test Wright modificntion Note the showers of petechinc below the level of the blood pressure cuff Subclinical and even clinical scury 1 cry common in our present civilization be cause of the frequency of diet fuddists per sons who believe all citrus fruts disagree with them in the treatment of peptic ulcers and colitis the physici in slould alu nys ensure in adequ itu intake of utimin C ire

·1.19
Case $1 Ulcers
IIYPERTENSIE ISCHEVIC ULCE RS
In some patients with arterial hypertensie mas become he morthiga then necrotic Thuis
disease the arterioles of the skin become can occur (ten in the presence of strongh
sclerotic and thrombosed Small areas of skin pulsating lirger vessels
Case $1 Hypertensive Ischemic Ulcers
Large recratic ulrer in lower
third of tibia
Punch grafts covering ukur
Thus patient is a man 41 years of e He
had been known to bac had high blood pres
sure for man years His pressure while under
our obsen tion ranged from 200 to 230
sistolic over 120 to 140 diastolic All the
penipheral pulses were strong oscillometric
reidings were normil The left figure shows
the large necrotic ulcer that had formed over
the lower slun This was debrided and pinch
Lrafts applied as shown in the right figure
Successful bunling was obtuned The patient
responded very well to Russolia theropi His
blood pressure fell to a range of 150/00 and
has been maintained in this region for a four
lear period of follow up During this time no
further ulceration has diseloped

·148 Diseases of the Small Vessels Casc 80 Clinical Scurvy Coalescing petechral rush with extensive hemosiderin for mation from old hemorrhage A small ulcer has formed Wright modific ition of Rum pel Leede test This 60 year old woman compluned of 1 rash over her lower extremities She gave 1 history of having abstuned from all run foods for several years A Rumpel Leede test Wright modification as shown in the right figure give innumerable petechiae Blood vitamin C level was 03 mg per 100 ml She was gwen 1000 mg per day of vitamin C orally and injections of a similar amount intravenously twice weekly The increased capillary fragility mp idly returned to normal The rush cleared er cept for the hemosiderin deposits which remuned as a brown stun The left figure shows a coalescing petechiul rish Extensive hernosiderin formation from old hemorrhage is present A small ulcer his formed The right figure shows the Rumpel Leede test Wright modification Note the showers of petechiae below the level of the blood pressure cuff Subclinical and even clinical scurvy a very common in our present civilization be cause of the frequency of diet fuddists per sons who believe all citrus fruits disagree with them in the treatment of peptic ulcers and colitis the physician should always ensure in adequrte intake of vitamin C ·7 Blood Vessel Tumois HIEMANGIOMA 1 varnible hemangioma (birthmark etc) is a be Tiga growth often present at birth It consists of vascular spaces supported by amount of Abrous stroma lemangiomas muy he subdivided into the following types i Casemous Ilemangioma This is ? hemaproma which contains lurge vascular Spaces Thus fact may be ascertained by the appearance of the lesion and especially by pressure upon the lesion It gives the sensa tron of a reduced resistant to pressure as compared to normal tissue 2 Capillary Flemangioma A hem ingioma which contains small vascular sprces is a cap hemangioma This appeirs as a small red spot Pressure produces a piling of the 3 Plexform llemangioma A plexform hemangioma is one which is not well circum scribed due to cxtensnemmification of the Island sessels tlist often penctrate deply into thic surrounding tissue 4 Sclerosing IIemangiom. This is lie mingioma in which the blood sessels are con structed by proliferating fibrous tissue In the end stage m iny of the csscs are obliterated giving the lesion a superficial resemblince to 7 fibroint Thic sclerosmg process is only cut dent clinically after long continued obsen 1 tion 5 Syndromes with Ilemangiomas These are rare conditions (a) Vuluplc hemangiomas and choudso mus (kasts syndrome) (b) Hemangiomas of thu rotina and contri! nervous system sometimes 1550cite mith cysts of thc pancreas and kidnet (Lucas Or von Hippel Linduus disease) are. HEVANGIOENDOTHELIOMA 6 Bemgn 7 Malignant A hemangioendothelioma hke hemangioma contains vascular spaces Clification and ciption from the Womenclature an! Citerta fut Dia, nosis of Dut ases of the Heart an! Blood Tesscls 5th ed Tew York New York Ileart Association Inc 1973 but unlike a hemangioma it also contuns solid nests of proliferating endothelium There are all graditions between Jesions m which the proliferatie endothelium is markedly 101 plastic with the vascular spaces crudely formed to the opposite extreme in which the Sascular spus are prominent and the 151

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·153
Sarcoma
hages manifested by epistaxis hematuria etc
The disease is sud to be transmitted by either
sex as a simple Mendelian dominant
(b) PAPILLARY VARICES (SENILE ACI
OVA CAYEVVE PEPPER Srot) These are small
red compressible localized benign cutine
bus swellings consisting of a single dilated
Vessel and
occurring
lith
incre using
fre
quency after middle age They ure benign
(c) SPIDER ICIOSA (SPIDER Nets Ne
VUS ARA ELS) This is 1 cut weous losion con
sisting of a central pulsating arte riole from
which small dilated capillaries radiate out
utrd producing af inciful spider the app ir
ince The lesions often i 180crd with
Incr elist 15cs ind pre nincy but mis occur
independently The nren mit un from a few
millimeters to several contueters

·152 proliferative endothelium less conspicuous It is impossible to differentiate morphologically betu cen hemangioendotheliomas which metis t isize and those which are locılly invasive Clinical manifestations depend upon the Blood Vessel Tumors organ involved When the skin is involved there is a circumscribed tumor usually bluish and usually compressible It may be tender or punful or both The size varies from a few millimeters to several centimcters SARCOMA 8 Angiosarcoma This term is seldom used Many pathologists reserve the term sar com for neoplasms arising from mesenchy mal derivatives other than blood vessels If many of the neoplastic cells are in plastic but in places sufficiently differentiated to form vascular spaces the pathologist mihes the dugnosis of malignant hemangioendothelioma rather than angiosarcom. Some sircomis ire so highly undifferentiated that the pathologist cannot be certain of the parent tissue 9 Kaposis Sarcoma This term is applied to multiple pigmented lesions composed of dilated capillaries fibroblastic proliferations inflammatory cells ind hemosiderin deposits The hemosiderin deposition is due to extra vasıtions of blood from ruptured capill tries The lesions usually appe ir first in the skin of the extremities There is n bluish mass of blood vessels extending into the adjacent tis sues and of slow growth Miles are more com monly affected than females Autopsies have demonstrated that visceral lesions do occur but they are usually clinically undetectable The werage life expect incy is said to be 5 to 10 yeirs It is not at all certain whether this entity is really a surcom? Some pathologists believe that it is essentially in inflammatory lesion 10 Ewings Sarcoma It is widely held that Ewings surcomi is essentially in endo theliom and indeed the tendency of the neoplastic cells to surround spaces do sus gest in endothelial origin However Ewings surcoma alw zys prises in the sheletal system frequently in the vertebrne It is therefore listed under bone tumors The initial symptom usually is pain Il Glomus (Angioneuromyoma) This benign tumor is a hypertrophied circiture of the specialized artcrios enous inastornoses found in the periphery and which ire con cerned with temperature control It consists of blood vessels imbedded in smooth muscle epithelioid cells and nonmyelin ited nerve fi bers These benign tumors may be situated inywhere in the skin but classically they ure found on the hinds and feet frequently be neath the nuls Typically the tumor cuses prrowsms of severe rudrating pun especulls on pressure upon the tumor The tumor is usually small seldom measuring more than 1 few millimeters in drumeter and when super ficial is slate gray in color Complete c\cision results in cure 12 Hemangiopericytoma This term used to refer to a neoplism which resembles z glomus ercept that the epithe Jod cells zre licking Most are benign 13 Telangiectasis Telangiect zsis nu not be a true neopi zsm It may be a dilatation of prcexisting vascular channels either venules capillaries or arterioles rather than inco plastic proliferation of new vessels (1) HEREDITARI HEMORRHAGIC TELANGI ECTASIS This is churacterized by numerous dilit itions of the cut ineous ind mucous mem hrine capilliries and venules These inoma! les seldom measure over 4 mm Rupturt of the mucous membrine lesions occasions hemorr 1s

·Case 82 kaposis Sarcoma
155
1
Multiple areas of tumor on leg
Lesions under tongue and on lips
Biopsy in low power
Biopsy in high power

·154 Blood Vessel Tumors Case 82 kaposis Sarcoma (Multiple Hemorrhagic Hemangioma of kaposi) The This middle aged mun noted peculiar brownish discoloration on his feet and shins five years previously The areas itched but otherwise did not bother him The lesions slowly progressed up the legs They were ac companied frequently by tiny hemorrhages into the skin The hemorrhages subsided and left behind deposits of hemosiderin Finally lesions perred on the mucous membranes of his mouth id lips The upper left figure shows multiple are is of tumor on the leg The wei marked off by crayon w is biopsied and is shown in the two lower figures Note the mottled discoloration caused by deposits of hemosiderin also the tiny dirker reis of fresh hemorrhage upper right figure shows lesions under the tongue and on the lips The lower left figure is the biopsy in low power Note the deposits of hemosiderin the overgrowth of endothelial cells with a tendency to form new capillaries The lower right figure is a lugh power view of the lesion Note the sarcom tous changes in the vessels prknotic nuclei ind the numerous mitotic diy isions TREATVEVT The lesions can often be held in check for many veurs by judicious use of Try therapy PROGNOSIS From the time of dragnosis the life span is usually 5 to 10 yeurs Visceral Je sions do occur that ire often thought to be part of the primary tumor

·157
Case 84 Kaposis Sarcoma
Case 81 Kaposis Sarcoma in a Middle Aged Iloman
Lesions in both feet and toes
Ulcerated neas on internal
malleolus
The left figure shows the lesions in both
feet and toes Note the symmetry of the le
sions the dark brown staining of hemosiderin
and the intense brown color of fresh lesions
The right figure shows the internal mal
Itolus Aote the ulcerated areas where the
tumor has croded the skin also note the dark
brown fresh deposits of tumor on the inner
surface of the second toe

·156
Blood Vessel Tumors
Case 83 hyposis Sarcoma
Yure
VA
This 75
year old man developed this malig
nant tumor of blood vessels at the age of 70
He had recerved extensive x ray therapy This
slowed
progress of his disease which
advanced slowly but definitely The photo
graph shows the tumor infiltration in the feet
legs and hand The brown areas are sites of
hemosiderin deposits from hemorrhages in the
tumor tissue A small ulcer over the dorsum of
the foot has appeared
up the

·157 Case 84 haposis Sarcoma Case St hiposis Sarcoma in a Videlic Aged Woman Lesions in both feet and does Ulcerated arcus on internal mallcolus The left figure shows the lessons in both feet and toes Note the symetry of the le- $ions the dark brown staining of hemosiderin and the intense brown color of fresh lesions The right figure slows the intenul muul lcolus Mote the ulcerated in is where the tumor has eroded the skin also note the durk brown fresh deposits of tumor on the inner surface of the second toe

·158
Blood Vessel Tumors
Case 85 Angiosarcoma
The illustration is the leg of a 52 year old
woman who developed a purplish lesion on her
foot one and a half yeurs previously The lesion
gradually spread to involve a wide area Note
the extensive infiltration over the ankle above
the instep as well as the patchy infiltration in
the midleg Biopsy of the lesion showed a
malignant surcoma of blood vessel type Me
tast isis had developed in the groin The casc
was too late for surgical intervention ray
therapy was used for palliation

·159
Case 86 Hemangioma
Case SG Cavemous Blemingioma
Extensive lesions on fore
arm arm thorax chest and
abdomen
Close up of large ciemnous
arers on the arm
This 30 year old man was bom with er
tensive cavernous hemangiomas of his trunk
and arms Seven years ago at age 23 he com
menced to have Jacksonian epileptic seizures
probably indicating a similar lesion in the cor
tex of the brain
The left figure shows the extensive lesions
on the forearm on thorns cliest ind abdo
men The right figure is a close up showing
the large chernous spices on the man Be
cause of the extensne degree of the lesions in
this patient no therapy " is attempted

·160
Blood Vessel Tumors
Casc 87 Cavemous Hemangioma
Dilated pools of veins merg
ing into large hemangiom?
Distribution of lesion from
knee to hip are?
This 10 year old girl was born with in
extensive hemingiom?
The left photograph shows dilated pools
of veins which merge into a large hemangi
oma No signs of arteriovenous anastomosis
could be demonstrated The right photograph
is a lateral view showing the distribution of
the lesion from the knec to the hip area At
a younger ge this could hue been treated
with sclerosing injections with very little if
any scarring It might hue been quite suc
cessful At this age because of the wide er
pinse of the lesion whatever type of therapy
is attempted wall lene se irrig

·161
Case 88 Hemangioma
Case SS Cavernous Hemangioma
Before theraps
One you follow up
This two week old baby has a large cas
crnous hemangioma in the elbow region (left
figure) Many of these lesions decrease in size
as the child grous but this covered such a
large area and invoked such large vessels
that it was deemed advisable to treat it at
once The lesion responded quichli to scleros
ing injections using Sunnsol very little scar
nng resulted A series of 10 injections at one
month inter als was given with the result
shown in the right figure onc veur after ther
apy

·162 Blood Vessel Tumors Case 89 Chvernous Hemangioma y mg $ Fungating tumor Two month follow up This six month old infunt has a large fung ating cavernous hemangioma which extrudes above the surface and penetrates deep into the tissues of the back She was trented by implanting ridon seeds into the tumor mass The left illustration shows the extensie tu mor The right illustration wis taken two months later Notice that the tumor has shrunk the fungating area has sloughed and been covered by epithelium Small telangiectases remun around the periphery When the child is about eight or nine ye urs of age plus tic surgery will be done removing the scured area and pulling the tissues together to gre ? good cosmetic result ·103 Case 90 llemangiomr Case 90 Capıllary IIemangioma A Capillary hemangioma on face Three year follow up as This child was born with a large red cap illary hemangioma on the face corresponding to the third or submaxillary division of the trigeminal nene It covered the check shown in the left illustration extending from the jais line to the ear and across the face Because these lesions frequently fade is the child grows older and because whatever fonn of treatment used would leave some scar for mation it was deemed advisable to watch this patient and to postpone therapy The second picture at the right was taken three years later The lesion has shrunk in size and in color and is lirely visible except when the patient cries as in the photograph As times goes on it can be expected to fulc still further in liter lift it will be possible to con ccal the residual traces of the lesson with cos metics Some of these capillary hem ingiomis persist into adult life at which time satisfac tory cosmetic result cin somnctunes be ob tained by tattooing them so that they bkend in with the normal color of the skın This type of tattooing has heen described by IIerbert Con wy (Tumors of the Skin Springfield, ili Charles C Thomas and Co 1956)

·164
Blood Vessel Tumors
Case 91 Capullary Lymphangioma
Capillary hemangiomi cov
ering left side of body
Close
up of leg showing le
sion and ulcer above malleolus
This 35 year old colored woman Irzs a
capillary lymphangioma which covers almost
the entire left half of her body Notice how the
lesion shown in the left figure involves
the half of the face the left arm the left chest
and the left leg
The right figure is a close up of the leg
illustrating the diffuse nature of the lesion
and the formation of an ulcer above the mai
leolus This tissue is very fragile and easily
traumatized When ulcers for the ure dif
ficult to heal In this case healing of the ulcer
was induced by elev ntion rest ind intimi
crobial ointments The diffuse primirs lymph
angioma could not be satisfactorily traited

·105 ase 92 Angioma Case 92 Pulsating Angioma 7 7 Close up of lesion on forehead Two lesions on elbou This is also known as primary angiomi nevus araneus or spider nevus This 27 year old girl noticed the develop ment of small red skin lesions since the men arche They are located on the arms trunk Jegs with scveral on the face Each is com Yosed of a central red dot which pulsates and from which small vessels radiate like the spokes of a wheel There is no family history in her case wr has thert been any spontane ous bleeding from the nose or other mucous membranes such as that characteristic of the hereditary Rundu Osler Weber syndrome She is in excellent health her liver und endocrine status is normal The left illustration shows a close up of the lesion on her forehead The right illustration shows two of the lesions on her clbox When these lesions occur in other patients 113 the mucous membranes they are apt to blud profusely and extensively on slight truum? Recently it has been suggested that the lesions are associated with an imbalance of estrogen production or estrogen conjugation by the Inver Therapy has been directed to correcting this factor with success in some cases

·166
Blood Vessel Tumors
Casc 93 Hematocele
This four year old boy fell off lus tricycle
and traumatized his left supracuiculır irei
A large round swelling shown in the photo
graph developed in the neck It simulated ?
cyst or 1 lymphocele from truumi to the lyın
plantıc duct Aspimtion proved it to be an
hem itocele It subsided without further ther
up The prompt application of ice to develop
ing hematom u is of great value in stopping tlie.
formation of these lesions

·167
Case 91 Angioma
Case 94 Pulsating Angiomi
In this patient (The New York Hospital
#5.066) numerous large spider an somas
Were found on the cheel at the angle of the
law the region of the clavicle and over the
sternum as seen in the illustration Thest
lesions are frequently found in patients who
hare portal hypertension due to cirrhosis of
the Inver They are most commonly found ex
terally at the level of the diplırım At pres
ent the tre believed to be due to loss of the
lusers ability to conjugate estrogenic hormones
ind are 1 sign of decre ised liver fumction
This however 15 not conclusively estals
hshed as the definitive explın ition This 57
year old patient died of cirrhosis of the incr

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·INDEX puncte IS 62 Blood vessel tinors 151 167 Acrocyanosis 88 89 Anastomosis arteriosenous 126 127 136-137 Buergers disease Sue Thromlx, ingilis obliterins Aneurysm 125 139 abdominal aortic 128 129 Cilcification of thxlommal norin 11 Carcinoma arteriovenous breast 50 congenital 134 135 traumatic 138 139 atherosclerotic 123 Causaluu 118 120 Chilblains 92 congenital 125 dissecting of aorta 130 131 Cor pulmonale 41 embolic 126 Cryoglobulinem 116 117 aliopathic 126 innomunate artery 132 133 Dialctes mellitus 811 16-17 cotc 126 svphilatıc 125 Effort syndrome 105 traumatic 126 Embolus Angroma pulsating 165 167 lower extremities 27 Anticoagulants 2 4 5 38 48 49 pulmonary 51 54 56 63 Arterial diseases 1 28 Ergot poisoning 114 115 Summary 6 Ergotamine poisoning 115 Arterial ernboluzation 1 2 27 28 Arterial insufficiency chronic 56 Foley arm edema stand 75 prognosis 6 Foley elastic sleeve 69 treatment 56 Fragility of vessels increased 142 113 anticoagulants 5 Frostbite 92 93 drugs 5 erertise 5 Gangrene 15 17 20 110 113 gravity use of 5 hygiene general 6 Hemangioendothelioma 151 152 sympathectomy 5 Hemangioma 151 ulcers care of 6 capillary 163 Vasodilatation 5 cavemous 159 162 Astenal occlusion acute 15 Heraatocele 166 adaptive mechanisms I Hypertensive ischemic ulcers 149 diagnostic signs 1 physiologic changes 1 Intermittent claudication 7 treatment 25 anticoagulants 4 Lixedo reticulans 90 91 direct surgery 2 Lymphedema 65 83 classification 65-66 etertise 4 general mersures 5 clinical features 66 67 gravaty use of 3 masne 70 71 79 tissue ability maintenance of 4 medical management 68 Vasodilation 3 of art 72 75 Arteriosclerosis Vonckebergs medial type 18 19 of hind 81 Atherosclerosis obuterans 7 17 of leg 80 Lulary vein thrombosis 108 109 119 praecos 76 79 treatment 65 169 ·170 Vonckebergs medul type See Arteriosclerosis Neurovascular syndromes of shoulder girdle 105 107 Nitroglycerin, 1 86 Occlusion of bufurcation of tort 12 Small vessels diseases of 141 149 St isis dermatitis 29 38 St isis ulcertion and edem. 82 83 Sudeks atrophy See Clusalgı? Sympathectomy 4 5 Syndrome vxıllary vain thrombosis 108 109 119 costoclavicular 105 effort 108 hyper abduction 105 107 neurovascul ir of shoulder girdle 95 105 postphlebitic 30 Runnuds 113 scalenus anticus 105 Periarteritis noclosi 122 Peripheral neuritis 112 113 Permeability of vessels increased 143 144 Pernio 92 Phlebitis 30 chronic 2 chopathic 49 with gangrene second try to sosp ism 110 111 Pulmonary embolism ind infiction 43 62 complications 44 differental diagnosis 45 prevention ind treatment 15-18 Summary 63 symptoms 43 Purpuri 142 146 allergic 143 clue to wtuminosis 142 hematogenic 143 idiopathic 143 infectious 142 menstrual 143 secondıry to increased venous pressure 142 senile 143 146 tovic 142 with granulocytosis 144 145 Riynauds dise ise 86 87 113 121 Runtuds syndrome 113 Rheumatoid arthritis 121 Thrombi multiple riscular 50 pulmonary 51 Thrombo inguts obliter ins (Buergers disers 20 26 101 Thrombophlebitis 30 38 42 49 110 after care 38 39 anticongulant administration 38 classification und etiology 36 diagnosis 36 37 pelvic 58 59 trentment 37 38 analgesia 37 anticoagulant 37 intifungus 37 constitutional 37 clevation 37 heat 37 nerve blocks 37 rest 37 Thrombosis 1 Ulcer ition 6 15 33 35 93 149 157 Sarcoma 152 158 161 167 ingio 152 158 Lwings 152 Kaposis 151 157 Scleroderma 96 103 treatment 96 Scurry clinical 148 subclinical 147 Serotonin 1 ricose veins 29 32 35 38 40 41 I asospasm 1 85 123 Venous dise uses 29 63 \ enous insufficiency 29 35 chronic 34 45 postphlebitic syndrome 30 sclerosing by the empty vein technic 30 surgical measures 31 trentment 31

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·170 Vlonchebergs medul type Sec Arteriosclerosis Neurov iscular syndromes of shoulder girdle 105 107 Nitroglucerin, 1 86 Occlusion of bifurcation of north 12 Inde Small vessels diseases of 141 149 Stasis dermatitis 29 38 Stusis ulceration and edemı 82 83 Sudeh s atrophy See Causalgia Sympathectomy 4 5 Syndrome will ary vem thrombosis 108 109 119 costoclavicular 105 effort 108 hyperībduction 105 107 neurovascular of shoulder girdle 95 105 postphılebitic 30 Rzyn iuds 113 scilenus inticus 105 Perurteritis nodos1 122 Peripheral neuritis 112 113 Permeability of vessels increased 143 144 Pero 92 Phlebitis 30 chronic 12 Idiopathic 49 with gingrene second ry to visospasm 110 111 Pulmonary embolism and infiction 43 62 complications 44 differentral dngnosis 45 prevention and treatment 15-18 summary 63 symptoms 43 Purpuri 142 146 allergic 143 duc to autuminosis 142 hematogenic 143 idiopathic 143 infectious 142 menstrual 143 secondary to increased venous pressure 142 senile 143 146 toxic 142 with agranulocytosis 144 145 Raynauds disease 86 87 113 121 Raynauds syndrome 113 Rheumatoid arthritis 121 Thrombi multiple vascular 50 pulmonary 51 Thromboanguitis obliterins (Buergers dise ise) 20 26 104 Thrombophlebitis 30 30 42 49 110 after cire 38 39 anticoagulant administration 38 classification ind etrology 36 diagnosis 36-37 pelvic 58 59 treatment 37 38 inalgesia 37 anticoagulant 37 antifungus 37 constitutionn) 37 eles ntion 37 hent 37 nerve blocks 37 rest 37 Thrombosis 1 Ulcerntion 6 15 33 35 93 149 157 Sarcoma 152 158 164 167 angio 152 158 Eungs 152 Kaposis 154 157 Sclerodermi 96 103 treatment 96 Scurvy clinical 148 subchnien! 147 Serotonin 1 I aricose veins 29 32 35 38 10 41 I asosp ism 1 85 123 Venous disenses 29 63 Venous insufficiency 29 35 chronic 34-45 postphlebitic syndrome 30 sclerosing by the empty sen techne 30 surgical measures 31 trentment 29 31

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