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·Peripheral Circulation
in health and disease
Walter Redi ch, ND, CACP
Associate Irofessor of Clinical Medicine New lork Unuersity College of Vedcine
AND
Francisco F Tangco, MD, BS
Assistant Irofessor of Vledicine Uansersity of the Philippines Medical School Harula
11 Research Fellow Aero l ork Unstersity College of Aedicine
WITH A SPECIAL SECTION 3
R L dec II Saunders, MD, FRSE
Professor and Ilead of the Department of Anatomy Dalhousie Unu ersity Aledical School
Hallax hora Scotia Canada
AND ASSOCIATES
A2
GRUNE & STRATTON, NEW YORK 1957

·Library of Congress Catalog Card No 56 12893
Copyright 1957
GRUNE & STRATTON INC.
381 Fourth Avenue
New York City 16
Printed and Bound in USA

·Contents 11 PREFACE Chapter 3 Alterations in Blood INTRODUCTION Flow due to Fxtrinsic Causes 58 PART 1 BASIC ASPECTS OF Traumatic Injuries 58 PERIPHERAL BLOOD FLOW D ea e and Injury of the Nervous Chapter 1 Anatomy and Physi Sy tem 58 ology of the las Disturbances in the Endocrine System 63 cular System 1 Changes in General Circulation 61 The Va cular Tree and its Inner ation 1 Abnormalities of the Musculo Skeletal Blood Supply of the Upper Extremity 1 System 61 Blood Supply of the Lower Extremity 3 Changes in the Composition of the Histology and Innervation of the Blood 65 Vascular Tree 4 Sensitivity Reactions 65 The Concept of Wasomotion 11 The Mechanism Involved in Vasomo PART III PHYSIOLOGIC tion 12 RESPONSES TO DISTURBANCES Neural 12 IN BLOOD FLOW Humoral 13 Metabolic 13 Chapter 1 Development of Second Vasomotor Stimuli 13 ary (Collateral) Circu Physiologic 11 lation 77 Pharmacologic 11 Chapter 2 Restoration of Primary Circulation 81 Chapter 2 Evaluation of Blood Flow 15 Clinical Methods History and Examı PART IV MANAGEVENT nation 15 AND THERAPY Clinical Methods Te ts and Proce Cliapter 1 Restoration of Occluded dures 20 Primary Arterial Specialized Methods of Measurement 25 Channels 81 Te ting of a omotor Rie ponses 30 Medical Means 81 Va omotor Respon es in the Extremities 32 Surgical Means 85 PART II PATHOLOGIC Chapter 2 Enhancement of Second ALTER 1TIONS IN PERIPHERAL ary (Collateral) Arte BLOOD FLOW rral Blood Supply 86 Chapter 1 Acute Intrinsic Vascular Medical Means 86 Disorders 42 Surgical Means 92 Arterial Segment 42 Chapter 3 Management of Impair Venous Segment 41 nient of Venous Drain Minute Ves els 46 age 95 Chapter 2 Chronic Intrinsic Medical Means 95 Vascular Disorilers 16 Surgical Means 98 Arterial Segment 46 Chapter 4 Therapeutic Measures Venous Segment 51 Influencing Primarily Minute Vessels 55 the Minule Vessels 100 111

·14
Chapter 5 Management of Under PART V THI ANATOVIC BASIS OF
Iving Conditions and
TII PERIPIJERAL (IRCULATION
Complications 101
M MAN
Trtainent of (eneralized la cular Dis
Introduction
113
esse
101
Experimental Procedure
113
Treatment of Related Extravascular
Extramuscular Arteries
115
Conditions
101
Intramuscular Arteries
125
Management of Complicating Sequelae Arteriovenous Shunts
132
of Disturbances in Peripheral Blood
Flow
102 inde
116

·Preface The recrude cence of intere l in the treat a well as a rather complete enumeration of ment of peripheral va cular di ea e engen the resulting di case entities of the peripheral dered by the deselopment of a large number circulation both arterial and venous The of synthetic drugs makes the present volume third part ets forth the physiologic va cular most timely It is thoroughly up to date and adju tments which ari e in re pon e to the becau e it is o comprehensive covering all various pathologic tate while the fourth sec the main a pects of peripheral va cular di lion presents an up to date summary of the ease it should I believe not only be useful available means of management of arterial and to medical tudents in general and particularly venous di ea e both medical and surgical to workers directly concerned with this field This well planned arrangement will thus pro but it should also prove invaluable to practi vade easy acces for both tudents and prac tioners of general medicine titioners to the particular points in which they The first part of the hook deals thoroughly are intere ted with the pertinent anatomy and physiology of The special fifth ection should prove es the va cular sy tem together with a detailed pecially rewarding to medical students and description of both the very simple clinical investigators interested in basic science as te ts of the circulation and the more compli pects of this field as hould the extensnclub cated laboratory procedure, The econd part liographie that appear throughout the volume gives an unusually well organized de cription and form an integral part of it of the pathologic alterations that can occur J MURRAY STEELE MD Professor of Medicine Nere I ork Uniuersity College of Vedicine and Director Neu Jork Uni 1 CTsity Reseatch Service ·Introduction THE HE INCREASINC I\TEREST in diseases of at present the most accurate demonstration of peripheral blood vessels and the likew e the fact that physiologic deductions can be increasing tendency to provide a sound phys based on structural information only if such jologic basis for their proper ei aluation and information is complete This necessity for management have led to a large volume of basic facts of cour e applies to pathologic nes investigative work in this field the de conditions as well or even more velopment of new methods of investigation It is nece sary to realize that changes and and the application of these methods to clinical disturbances in peripheral blood flow are not medicine Such fruitful though widely cat necessarily associated with de mon trable struc tered studies call for a re et aluation of the tural changes and, even more important can problems facing the student of peripheral car not always be easily correlated with such By culation and the disease states stemming from now it is common knowledge that morphologic ats disturbances finding even of secured through biopsy do This book is an attempt at such re es alua not necessarily reflect functional changes in an tion Consequently pathologic manife tations organ Moreover ob erved tructural changes have been correlated wherever posible with may be compatible with intact physiologic deturbances of specific physiologic mechan functions and disturbed function may be 1 ms less emphasis has been placed on rigidly found in the ab ence of any demonstrable labeled classifications of the peripheral vas structural changes This of course does not cular di eases Many workers in the field mean that a structural classification should or believe that all too frequently such detailed can be entirely disposed of It remains a ne cla fications are not supported by sufficient cessity for didactic purposes however such pathologic and hi tologic eudence a cla sification hould be supplemented with Moreover knowledge of the ba ic anatomy and supported by correlation of di ea e mani of large and important parts of the vascular festations with demonstrable changes in phys tree has been far from complete The recent Jologic function work of Dr Saunders and his co workers on Except for Dr Saunders section du tra the anatomy of the blood channel, supplying tions have been limited to such anatomic and human keletal muscles and on the peculiar physiologic charts and diagrams as appear in functional di tribution of these channel toth dispen able for better under tanding of the in the musculature fill in ome of the gaps in ba ic mechanisms of peripheral blood flow our knowledge Dr Saunder hndings hale Mu Irations of apparatu as well as of clinical been incorporated in this book as a pecial manife tations of vascular di ea e haie leen and separate section becau e they represent omitted ·Part I Basic Aspects of Peripheral Blood Flow Cu4P 1 ANATOMY AND Pin SIOLOGY OF TIF VASCULAR SYSTEY The vascular tree and its innerva tion Bloo l supply of the upper extremity of th lower extremity histology and innervation The concept of vasomotion The mechanisms of vasomotion Meural Humoral Metabolic Va oniotor stuuli Physiologic Pharmacologic tation Vinute circulation Tenou circulation Ct nical methods 2 Tests and procedures Artenal circulation Vinute cir culation lenous circulation Special methods of measurement Ceneral circulation Arterial cir culation Testing of sa omotor respone Temperature changes of the internal environment of the erternal en Vironm nt Pharmacologic agent Yasomotor re ponses in the ex tremitie Relationship to the heart la cu lar bed within the extremity Relationship among vascular beds CAP 2 EVALUATION OF BLOOD FLOW Cl n cal method 1 litory and examination Arterial circulation-In pection palpation percussion and auscul Chapter1 Anatomy and Physiology of the Vascular System THE VASCULAR TREE AND ITS INNFRVATION which is the direct continuation of the ub clavian branch of the aorta After giving off its branches to the inuscles in the houlder girdle and the upper arm and tho e that form LENGTHY DESCRIPTION of the entire is scope of this book such information is read arteries in the che t at the lower end of the ily obtainable from any tandard text on anat axilla it continues directly into the brachial omy However a better under tanding of the artery Accompanied by two brachial veins subject requirts at least a sketchy review of and the median nerve the brachial artery the vascular tree with emphasis to a greater pa es downward beneath the brachial fa cia or le er degree on uch of its branches as are in the medial bicipital groove to the cubital concerned with the circulation in the extrem fox 3 where it hes upon the tendon of in er ties? tion of the brachialus mu dle covered by the 1 Blood Supply of the Upper Ex lacertus fibro us Its branches upply all the tremits The primary arterial channel to muscles of the arm and the humerus It the upper extremity is the axıllary artery also gnies off the superior and inferior uinar 1 ·2 PERIPHERAL CIRCULATIO IN JIE ILTI1 AND DISEASE arteries which supply neighboring muscles The blood supply of the hand and fingers and terminate by forming the cubital articu is derned principally from the branches of lar rete At the bend of the elbow the brachial the superficial and the deep solar arches artery divdes into two terminal branches the which are formed by the anastomosis of the radial and ulnar arteries At first the radial terminal branch of the ulnar artery with the artery runs between the lacertus hibrosu, and superficial volar branch of the radial and of the tendon of the biceps it then passes to the the terminal branch of the radial attery with ulnar side of the superficial radial nerse the deep volar branch of the ulnar re pec under cover of the brachio radialis and runs tres The common volar digital arteries downward in the groose between this and the from which the proper digital arteries arı e forearm flexors first in front of the tendon of and the volar metacarpal arteries are derned the pronator teres and then between the bra from the e arterial arche chioradialis and the flexor carpi radialıs It After further subdivding into branches of re ts for some distance on the flexor pollicis increasingly smaller caliber they ultimately longus and for a hort distance on the prona form the arterioles beyond which the mu for quadratus and in the lower third of the cularıy is lo t and the va cular tree consts forearm it I covered only by the antebrachial of endothelial tubes the capillarie its mall fascia and lies accordingly quite superficially et unit Through the capillary wall gaseous in front of the stylord process of the radius and metabolic exchange with the ti sues tahes Below this it bends under the tendons of the place Through the capillary beds blood is abductor pollicis brevis to the dorsum of the carried into the finest units of the venous poor hand, traiersing the radial fareola and there dion of the circulanon The e re els in ton passing between the two heads of the first join one another forming channels of increas dorsal interos eous muscle to the volar sur in, sizes face of the hand to form the deep volar arch Va cular drainage of the upper extremity The ulnar artery the other and larger ter is accomplı hed through a superficial and a minal branch of the brachial artery curies deep et of veins The cephanc vein starts at gradually toward the ulnar side of the volar the radial ide of the dorsum of the hand surface of the forearm being situated on the from the dorsal venous network and the digi origin of the flexor digitorum profundus and tal senous arches It recente tributaries from behind the median nerie and the superficial the olar surface of the hand the intercapitu Sexots It comes to be on the radial side of and pas es up the radial side of the the ulnar nerve remains covered hy the flexor forearm a far as the bend of the elbow where digitorum sublimis and Nexor carpi ulnarı it ana tomo es with the basılıc vein In ра е until the louer fourth of the forearm where it up the upper arm as a rule omen hat smaller lies between the tendons of the e two mu cles than it is in the forearm in the lateral by clone beside the ulnar ferie Tith this it upital groove to the deltoidespectoral tri runs over the radial urface of the plaform angle where it pierces the fascia to open into bone between the volar and the transier e the axillary vein The basılıc iein arı cs on carpal ligament and so covered at fort by the ulnar ide of the dor um of the hand It the palmans bress to the palm of the hand runs upward on the ulnar ide of the olar where it become the chief con tituent of the urface of the forearm to the level of the bend uperficial solar arch of the elboy here it umtes obliquely by Branches from the radial and ulnar arterie mean of the median cubital sein with the ce upply the mu cles of the forearm the radiu phalic It continue upward in the tipper arm in the medial bicipital groove and at about ulna and carpal bone and their finer ramifi rations from arou retia around the ellion the middle of the arm perce the bora hial and about the unit joint fa cia and opens into the medial Ira hal lar sein ·3 AATOMY AND PHYSIOLOGY the joint sein which uually its direct continuation genitalia as well as branches to the gluteal The deep Veins of the upper extremits ac ana tomoses and the arterial retia about the company the arteries a paired senze comites knee joint and the femoral trochanter Ther take origin in the deep and uperficial The popliteal artery begins at the adductor olar venous arches and terminate with the hiatu and run through the middle of the brachial vein from which the axillary rein popliteal fo- 3 reting on the femur and the formed They are connected bs numerou polerior urface of the knee joint and come anatomo-es with the uperficial reins and what medial to the sein pa -es between the during their course along with the arterie Ino head of the ga trocnemiu muscle over the members of each pair are frequently con the posterior urface of the popliteu mucle nected by tran ierce ana tono es and under the popliteal arch of the oleu The axillary vein runs through the axilla and in the popliteal canal divide into its two medial to and in front of the axıllary artery terminal branches the anterior and po-terior to open into the ubclavian sein which in tibial arteries It branches upply the li uen turn drains into the innominate vein The in the lower thigh, knee and upper leg and right and left innominate seins unite to form contribute largels to the ana tomo es around The uperior sena cava 2 Blood Supply of the Loner Ex The po terior tibial artery pa es donnward tremity At about the level and in front of with the tobial nerse beineen the oleus and the body of the 4th and 5th lumbar vertebrae the deep flexors and in the lower third of the the abdominal aorta bifurcates to form the les emerge from under the medial border of Ino common aliac arteries which run for 5-6 the oleu and comes to lie beneath the faccia cm along the medial border of the p oas It then runs behind the medial malleolus mu-cle crowd by the ureters and diside into under the laciniate ligament to the sole of the their two terminal branches the external and foot where it divdes into its terminal Internal iliac arteries without giving off any branches the medial and lateral plantar ar other branches of even moderate ize The teries the latter joining with the deep plan internal liac (hypoga tric) arterr upplies tar branch of the dor al pedal artery to form primarily the pelvic v cera the plantar arch It gives off nutrient branche and the mu cle of the pelvic girdle The er to the tibia fibula and the tar al hones ternal liac artery terminates on the border branches to the oft tuues of the leg and of the proa mu cle beneath the inguinal (Pou ankle as well as ana tomotic branches to the parts) ligament, where it pa s directly into region of the knee the lateral and medial the femoral artery after giung off malleol, and the calcaneal retia branche to upphs the lower abdomen the The anterior tibial arters which upplies inguinal region and the publ The femoral ju t about the ame tructures a. the porterior artery runs uperficially through the ulio tibial arter pa ses between the tibia and pectineal ío a and the femoral trigone cos fibula and runs downward on the anterior ur ered by the fa.cia Jata at fir t lateral to and face of the interoneou membrane It lies at then in front of the femoral vein and medial fir t beineen the tibialis anterior and the ex to the femoral nerve It then enters the ad ten or hallucı longu accompanying the deep ductor canal covered by the artorius muscle peroneal mense It på en under the cruciate and pa ces through the adductor hiatu into ligament resting on the bone and the car ule the popliteal fos a to become the popliteal ar of the ankle joint when it reache- che dor ten It goes off mu rular branches to the um of the foot it become known a the dur mu cles of the hip and thigh nutrient branches al pedal arter which pa ces upon the dor to the femur branches to the kin of the loner um of the foot between the tendon of the abdomen and of the publ to the external exten or hallucts longus and the exten or digi the perineum ome ·4 PERIPIIERAL CIRCULATION IN HEALTH AND DISEASE torum longus and resting on the dorsal sur ſa cia to open into the popliteal vein in the faces of the larsal bones takes a straight popliteal fos a Before its termination at re cour e to the first metatar al space where it cenes a vein from above the femoropopliteal onides into its two terminal branches the and by this and other anastomoses » brought first dorsal metatar al and the deep plantar into connection with the great saphenous artery It is also connected with the deep veins of the The foot and toes thus derive their blood lower leg by a strong branch supply from the plantar metatarsal and plan The deep set of veins has its origin from tar digital branches from the plantar arch the doubled anterior and posterior ubral veins medial and lateral plantar arteries from the that unite to form the popliteal vein which posterior tibial artery and the tar al dorsal is double only in the lower part of its course metatarsal and dorsal digital branch of the The popliteal vein follows the course of the dorsal pedal artery from the anterior tibial popliteal artery through the popliteal fossa artery, which branches also from the dorsal lying behind and somewhat lateral to it to pedal rete and contrılrutes to the lateral and become the femoral vein in the lower part medial malleolar and calcaneal retia of its course in the adductor canal at lies be The e arteries subdivide into increasingly hund the artery but pa es medially as it as smaller branches until they form the arterioles cends and in the region of the fossa ovalıs which in turn give off the capillaries The e and below the inguinal ligament it is medial munute vessels then unite with one another to the artery It recentes the deep femoral forming the initial portions of the venous sys vein the great saphenous and usually a num tem Subsequent unions of the e se sels form ber of small branches corresponding to the incrcasingly larger venous channels branches of the femoral artery These last are As in the case of the upper extremities the double as is al o the deep femoral though enous drainage in the lower extremities may this usually becomes single before its termi be duuded into a superficial and deep set natron The great saphenous sein the large t super In the lacuna vasorum the femoral vein ficial vein in the body arises on the dorsum continues directly to become the external iliac of the foot from the dorsal venous rele and sein receiving two tributaries the inferior from the medial end of the dorsal senous arch epigastric and the deep circumflex aliac and It receives some veins from the plantar re pa es upward medial to and behind the femo gion and then pa es up the medial urface of ral artery to form with the hypoga trc (in the lower leg and thigh inclınıng toward the ternal hac) vein the common iliac vein an anterior surface in the upper third of its terior to the acro liac articulation The two over the falciform border common ilac sein are the principal parietal of the fa cia lata and empties into the femo tributaries of the inferior vena cava ral vein On its way it receives numerous 3 Istology and Innervation of the branche tho e of the thigh being the larger Vascular Tree The sessels conshituting the and just before its termination it recentes the vascular bed differ widely in their calibers in uperficial epiga tric and uperficial circum different regions and on the basis of their fler iliac teins and usually also the external size structure and phs jological relationships pudendal The other large uperficial vein are divisible into four main groups the ar of the lower extremt) is the ma}} saphenous teries arterioles capslaries and sein • The sein which ari es on the lateral side of the arteries eem constructed to with tand high cor um of the foot lt a cends belund the pre sure Their wall are thick and contain a lateral malleolus on the pro terior urface of larger proportion of ela tic ti ue a maller the louer leg and in the groose between the proportion of involuntary mu cle filers an two hearts of the ga trocnemius it perces the outer sheath of connectile tis ue and an inner Cour e It pa e ·5 ANATORIY AND PHYSIOLOGY lining of endothelial cells the three coats The capillaries, eestral of which arise from froni without inward are called the (unica ad a le arteriole are from 2 to 10 microns in ventat media and intima The elements of diameter (in man a crage & microns) de the tunica ad entitia gradually merge with pending upon volume of blood flowing those of the surrounding loo e connective tis through them and from 05 mm to 10 mm sue which acrompanies ciery boodse sel The long A network of reticular fibers forms a relatise proportions of my cular and elastic thin membranous heath around the camil 11 sues vary with the size of the artery The lines and separates them from the elements wall of the largest arteries (eg the aorta) of the other tissules Usually capillaries are differ from the wall of arteries of medium accompanied by fired macrophages probably caliber (eg the radial artery) by its ab o undifferentiated cells of mesenchymal origin lule thickness and by its structure The middle and a fen cattered nerve cells which can layer of the largest se dls such as the aorta only be identified through the u e of pecial and the pulmonary artery are relatively poor hu tological methods in amphibians and cer in mu cular tu sue but contain a large pro tain other cold blooded vertebrates a catter portion of ela tic fibers The medium sized ing of peculiar cells with a number of long arteries contain a relatisely lar e amount of proces ps is seen lying upon the outer surface mit cle and le s elastic tissue while in the of the capillary wall these are called Rouget smaller ses pls the mu cle is greatly in excess cells after their di coverer The processes of The walls of the arteries are supplied with the neighboring Rouget cells join with one minute vessels - the vasa vasorum -- which another to form a loo e me hwork that en ramifs in the outer and middle coats The ar clo es the capillary These cells have been prial walls are abundantly prouded with seen to contract under electric tumulation the ries As the arterial sy tem is traced pe They have been de ribed by some workers on ripherally the ves els are found to break up the wall of human capıflaries others have into innumerable branches who e calibers br not been able to confirm this 8 The capil come reduced with ucce site du sons While laries form mazelike plexu es with one an the caliber of the arteries eradually decreases other and connect the arteral and enous sys as they rece de from the heart the sum of the diameters of the lumens of all the branches The capilline are from the terminal of the e arteries increa es greally the further branches of arteries and drawn into the le they are from the heart ginning of the venous sy tem they form ex The smallest arteries 03 mm in diameter clu le networks by their frequent branchings or maller are usually grouped in a separate and anastomo ps The e networks thoroughly ch s and are called arterioles These arte penetrate the various tissues they nourih LIP but on the average are in mu i in tances the me hes of the rapıllary about 02 mm in their outside diameter network adjusting them eles to the available Their wall are relatively thick and are com free spaces between the elements of the is posed almost entirely of smooth muscle lined ues have a polygonal hape and are of ap Hry in endothelial layer and sheathed by i proximately equal ize in all planes sranty adventina The mu cle fibers are richly The only component the capillary has in supplied with nerie fibers After a course of common with all other parts of the vascular ariable length the arteriolex lose their mus tree including the heart is the endothelium cular and connectite it sue coats lule the Vlot workers a tually bellese that the whole inner endothelial tube that remain are con capillary trueture con i ts only of the endo tinued as extremely fine hairlihe ve el - the ih hal tube Recently however kisch has capillaries in the tranition between the ar found ith the electron micro cope that this ferioles and the capillaries some authors dis endothelial tube much more complirated a tinguish precapillary arterioles tructure than heretofore a umedº tem who vary in ·6 I ERIPHERAL CIRCULATIOY IN HEILTIC AND DISFASF A B Fic 1 Schematic drawing of cros section through a capillary Mote depiction of the concept of a imple tube formed by a syncytrum of endothelial cell B Schematic draying of lon, tudinal a pect of a capillary depicting Rouret Meyer cells ad jacent to the tube with irregular erere cences of th cytopla m (bashet cell formation) In the livng animal it is usually possible been ob prved in the mi entery of the rabbit to distinguish the endothelial nuclei scattered the wing of the hat and the web of the frog along the outlines of the capillaries After Tonwiller 10 in man and Chambers and fixation and staining the wall of the capillar Zweifach" 1 in the animal have shown that les stands out clearly as a thin homogenous changes in the diameter of the capillary lumen membrane, within which the endothelial nu art dependent upon the state and shape of cle, are locnted at various distances from ont the endothelial cell rather than upon any another contractile elements The caliber of the capillaries in variou The tran iton betueen arteries and capil parts of the body varies with narrow limit larits and between capillaries and runs 14 related to the size of the red blood corpu cles gradual This applies to the tructure of the In man at averages around 8 microns l'at wall as well as the caliber of the ve sel How ent thun capillaries through which only blood ules capillaries are often found which pro plasma circulates probably do not exrt al ject directly from small arteriea before a com though great number of the capillaries are plete ramification of the latter has taken collap ed when the organ or li ue is resting place similarly accessory capillaries fre Then the organ begins to ſunction acties quently enter directly into a well des loped these collap ed capillaries may open up and mall vein blood then circulates through them It ha al o been shown that in addition to Studio made on king blood te els in the capillars sets orks above described there chamber in erted in a rabbit car indicate may be seen arterios enou anastomo es uhuch that rapillary contrartılıts in the mammal connect an arteriole directly to the venous does not depend on the Rouget cell Micro tem without undergoing finer suhdist on di cction tudies have shown that the endo It appears that phy Jologically they do not thelial cell mar contract after direct me chanı play an important role in ga (ous and meta cal iimulation Capıllary circulation has alo bolic exchange but rather act as shunts that ·7 ANATOVY AND PHYSIOLOGY FC IC Electron micro cop photos aph of cro ection through a capillary (h art of guinea PE) Noie (1) one sin le cell forms the capillary wall (2) the na leus is tinctly seen the Cytoplasın is of varying thickne al has protru ions of various shapes into the capillary lumen in whı h a red cell is seen (3) there is a di rath 5 mooth outer membrane and a d tinet Inner m mb ane" hi varie in thicknee (Ile electron micr scople photo raphs shoun fips ICD and Euere taken by Dr Bruno Aisch Directo of the Electron Microscope Labora fory of the American College of Carde logy the autho s are deeply indebted to Dr Arsch and u sh to express their thanks and app ecralion ) ·6 I ERIPHERAL CIRCULATIOY JN MEALTIT AND DISEASE A am B Fic i A Schematic drawing of cro, ection through a capillary Tote depiction of the concept of a simple tube formed by a syneytjum of en lothelial cell B Schematic drawing of longitudinal a ect of a capillary deputing Rouger Vejer cell ad jacent to the tube ith Irregular excre cences of the cytopla m (la ket cell formagion) In the lung animal it is u ually possible been ob ersed in the me entery of the rabbit to di tingui h the endothelial nuclei cattered the une of the bat and the web of the frog along the outlines of the capillaries After Tonsiller10 in man and Chambers and fixation and staining the wall of the capıllar Zueulachi 1 in the animal have hown that les stand out clearly as a thin, homogenous changes in the diameter of the capillary lumen menibrane within which the endothelial nu are dependent upon the state and hape of cles are located at various di tances from one The endot) cell rather than upon any another Contractile elements The caliber of the capillaries in sarious The tran ition between arteries and capil parts of the bods varies within narrow limit laries and between capillaries and veins i related to the size of the red blood corpu cle gradual This applies to the fructure of the In man it atera,es around microns Pat wall as well as the caliber of the ve el Hou ent thun capillarie through which only blood ever capillarie are often found which pro pla ma circulates probably do not eut al ject directly from mall arteries before a com though great numbers of the capillaries are plete ramification of the latter has taken collap ed when the organ or tu sue is re ting place cmilarly acces ory capillaries fre When the organ begin to function activels quentls enter directly into a well developed the e collap ed capillaries may open up and mall sein blood then circulates through them It ha al o been hown that in addition to Studis made on lisin, blood feels in the capillars networks aboie de cribed there chamber in erted in a rabbits ear indicate may be een arteriol enous ana tomo es hich that capillary contrastulots in the mammal connect an arteriole directly to the renou does not depend on the Rouget cell Flicro sy tem without undergoing finer ubdısı son di ectron tudie hare hown that the endo It appears that phy jologically they do not thelial cell may contract after direct mechani play an important role in ga eous and meta cal timulation Capıllary circulation ha alo bolic exchange but rather act as hunts that ·9 ANATOMY AND PIIYSIOLOGY Fic 1 E Electron micro copic photograph of cro s section throu h a capillary (heart of guinea pig) In addition to the features described under C the triangular large nucleus of a Rouget Veyer cell is shown sitting on the capillary wall Filiform ercre cences of the cytopla m Sirtually engulf the capillary

·8
FERIPUIERAL CIRCULATION IN IIEALTH AND DISEASE
!
FIC ID Electron micro copic photograph of oblique section through a capillary (heart of
guinea pigt In addition to the features d cribed under C is o nuclear cros ections are een
whi h may repre ent either ti o nucler or a single nucleu section d Inice

·11 ANATOMY AND PHYSIOLOGY ties the proximal innervation is supplied by ing caliber the blood is finally poured into postganglionic nerve fibers from the aortic the right auricle by two large trunk the su plexus in the abdomen The e fibers follow perior and inferior venae cavae The veins have the common and external ilac arteries to the much thinner walls than the arteries but like thigh and terminate at the proximal parts of these they po sess three coats intima media the femoral artery The di tal innervation to and adsenttia The middle coat is only a the smaller arterie arterioles and capillaries fraction of the thickness of that of a corre in the lower extremity is conveyed through ponding artery It i compo ed of a rela po iganglionıc nerie fibers running through trely mall amount of un triped muscle and a the nerves of the lumbo sacral plexus large amount of connective ti ue the elastic The existence of va odılator fibers in anı hi ue is canty The outer coat of the ve el mal as well established In man however is di proportionately thick being everal times they have not been demonstrated but their thicker than the tunica media The valves existence is very strongly suggested by clini present in ome of the larger veins are formed cal and experimental evidence 1 19 Vasodila by foldings of the tunica intima tor impul es emerge from the central nervous THE CO\CFPT OF VASOVOTIO system at three levels The highest level is through the cranial outflow of the parasym The mot basic physiologic characteri tıc pathetic division of the autonomic nervous of any organ or structure within the living system where the impul es are conveyed animal organism is its particular type of re through the chorda tympani the glo o sponse to stimul Blood vessels in general pharyngeal and the vagus nerves The ec respond by changing their (circular) lumen ond level is through the thoracico lumbar out the lumen becomes either narrower or wider flow where the vasodilator fibers presumably The physiologic proces of change of lumen pursue the same routes as the vasoconstrictor in blood vessels is called vasomotion When fibers The lowe t level is through the sacral ever the direction of va omotion toward outflow where the fibers are conseyed through narrowing of the lumen the term a constra the pelvic nerve Antidromic vasodilator tion is u ed whenever vasomotion tend to impulses are al o conveyed through the pos widen the ve el lumen the term va odilation terior spinal nerve roots ls u ed The end result in the latter ca e is Aside from the va omotor nerves other mostly referred to as a odilatation This nerve fibers may be een in the walls of the terminology has been used rather glibly and blood ves els These are medullated fibers and ha been accepted too uncritically it is nec are afferent conveying sensory (pain) im essary to define more clearly the structural pulses from the vessels as well as antidromic substrates of the e physiologic events (dilator) impul es The differences in tructure of the various The appearance of the first smooth muscle segment of the arterial tree—the relatie pro cells or denser collagenous fibers in the ve sel portion of mu cular and elastic tis ues vary wall indicates the beginning of a mall sein ing with the size of the artery (more elastic The concept of arterial and venous capıl tis ue in the larger and more mu cle in the laries in man is rather indefinite and it is maller) --indicate differences in function and often impossible to distinguish them by the physiologic behavior within the arterial sys width of their apertures from ordinary capil tem itself laries + It may be ju tifiably as umed from direct Their venous ends conserge to form first observation as well as from functional tet the maller sein or venules By the conflu ing that blood se sel of arterial nature that ence of these to form larger channels and the are characterized by the po e ton of a uccessive junctions of veins of ever increas clearly discernible mu cular coat can narrow ·10 I ENIPHERAL CIRCULATION IN HEILTII AND DISEASE can allow the blood to pass through the part fibers to enter the corresponding ganglia in with lesser or greater rapidity which at times the vertebral sympathetic chain shrough the may even cause the total short circuiting of white rami communicantes These preganglı the circulation to the exclusion of other parts omic fibers synapse with cells in the corre of the organ or tissue 13 A third, and seem sponding ganglia as well as in tho e of other inoly intermediate type of capıllary is een es levels Postganglioniu fibers wluch are non pecially in the skin At the bases of the der medullated an e from all the vertebral gan ma) papıllac, the arterioles are seen 10 ENCglia and join the spinal nerves through the off endothelial tubes which accend into the gray rami communicantes They continue papillac and turning upon themselves join peripherally and are distributed to the varı neighboring Joops to form collecting venules ous parts of the body together with the other These capillary loops are taqily demonstra (somatıc) fibers in the spinal nerses Vaso ble at the base of the fingernail where they constructor impul cs to the blood vessels of are seen arranged in horizontal rows of hair the upper extremities are conveyed through pin shaped vascular structures 14 Each capil pregan lonic fibers emerging from the first Jars loop consists of an ascendin, afferent through the erghlh or math rhoracic segmeal (arterial) limh an arch or transition piece of the spinal cord synap ing with the cells in and a de cendın, efferent (venous) limb in the sertebral sympathetic ganglia and trans tracapillary pressure has been shown to differ mitted through postganglionic fibers are in significantly in the various parts of the loop from the middle and inferior ccrucal and first The collecting venules anastomose with one and second thoracic ganglia Vasoconstructor another to form the ubpapillary enous Impul es to the les els of the lower extremity plexu es which in turn drain into the deeper are conveyed through preganglionc fibers cins For detailed correlation between anat emerging from the tenth thoracic and firt omy and physiology of the minute circula and second lumbar pinal egments and tion the reader is referred to the special cc through the ganglia by way of po iganglionic tion of this book (Part V) fibers from the twelfth thoracic through the The entire vascular tree is innervated by fourth acral ganglia The c nerves are des the autonomic nervous sy tem Va omotor tributed to the vesselsegmentally In the impulses are controlled by vasomotor centers upper extremities po tganglionc nonmedul (a vasoconstrictor and a vasodilator center) lated fibers from the middle and inferior cer that are located bilaterally in the floor of the vical gangha pass to the ubclavian artery fourth ventricle There is evidence that higher where they form a plexus like tructure in the vasomotor centers are found in the hypo outer coat of the ve el and its branches thalamus and even in the cerebral cortex 13 including the axillary artery These hbers Vasomotor nerves con ist of vasoconstrictor wluch constitute the proximal innersation of and vasodilator fibers The constrictor fibers the vessels do not extend beyond the proxı arise from nerve cells in the lateral horns of mal portions of the brachial artery Di tal the eighth cerucal or first thoracic to the sec parts of the ses els are innerated by post ond or third lumbar se, ments of the cord ganglionıc nerve fibers which are conveyed by (often referred to as the thoracico lumbar out Hay of the (somatıc) neries of the brachial low which constitutes the sympathetic divi plexus These fibers terminate at various levels sion of the autonomic nervous sy tem) These in the arteries up to and includin, the arte preganghonie fibers emerge from the cord rioles and capillanes In the les el wall the through the anterior sools of the thoracico came fibers form three d, tinct pleruses one lumbar spinal segments as fine medullated in the outer coat or tunica adsentitis another fibers from which they soon eparate to in the mu cular and a third betneen these gether with other somatic medullated motor tuo layer Similarly in the lower extremi ·23 ANATOMY AND THYSIOLOGY In general the sympathetic sa adılator adrenaline make such separation manda hlers ant tholinergic their action is medi १९१ lory ated through the liberation of acetylcholine A vasomotor effect of humoral factors not In om afectes adrenergic vasodilator fibers directly related 10 the function of the neural have been demonstrated the relationship of mechani me fems therefore demon trable ihe tran mittor sub tance (aretylcholine) lib only on the minute circulation Recognition erated upon their timulation to the adrena of the possibly great importance of the ac linlike ub tance me dating va con trichon tion of catechol amines or other humoral 15 anknown agents in the va omotor mechant m concern Insentigation of the respective roles played ing larger caliber ve els hinges on further in Buy the cerebro »nal and autonomic systems vestigation Such intestigation should broms eems to indicate that the ympathetic path and no doubt will be directed at (1) prou 24s and in particular the adrenergic fibers in or de proving the exzetence of an enzy are our tandingly respon ble for maintaining matic mechanism rumoral transmis artenal se el in general at a certain degree ion of a omotor impulses to the mooth of constriction this suppo edly expresed mu cle coat of arterial vps ely similar to that in tonicity of the pls and thus the term prosen for the neurohumoral transmission of va omotor tone has become well estab molos impul $ to skeletal musrles and (2) fistud 13 determining the role of any of the catechol Increased vasomotor ton is con equently amines in such a mechanism a ovated with va oloistertion while var 3 Metabolic Since the cla sac demon dilatanon repre ens 2 tate of relaxed vaso stration of the triple re ponsert and the as motor lone While the fore,oung hypothe is umption of the esi tence of metabolites act į applicable to the oricrial part of the car ing as I like sub tances no further real culation it is not as well established for the advance has been made in clanfying the sub vendus ay temand it can hardly be applied trates of a metabolic ja omotie mechan to the msnuite circulation where neither the It is by quile indirect methods that at existence of contractible elements or sympa can be demon trated that blood flow through thetic nerve thers has been conclu iseks keletal mu cles in man seems to depend upon proved work performance rather than upon sympat The neural mechanism ecems to dominate petrc innervation 33 4 kascular beds in varying degrees It seems that the skin bed is almoso I entirely controlled by it but this doe not apply to the skeletal VASOVIOTOR STIMULI mu Llar bed33 or to the vascular hed in the Vacomotor responses may be elicited cssen Dver $4 3 To what extent it controls blood nally in two ways either directly or via a te flow to the kidneys and the heart is not yet fex When assessing the effects of stimuli known Cerebral flow eem to be quite inde producing change in se el caliber it is pendent of autonomic 1a omotor control nece ary to realize that generalized or uni 2 tumoral la the light of tacteasian directional respon es of the vascular system #5 knowledge of neurohumoral tran my sjon A one entity cannot and do not exit the re eparation <f this type of controllin, mechan sponses of various vascular beds may differ im from the plain neural becomes diffi either quantitatively or qualitatively depend cult However the currence of vasopres of ing upon the nature of the timulus, 5 $ 34 and depres or ubi tances and the proven va o 38 46 49 where a part, such as an extremity rotile altion of certain known endocrine e contains more than one, vascular bed, it be crptions including the demon trable effects comes necessary to take that differennation of the catecholamin s adrenaline and not inlo account when as essing blood flow to the ism ·12 PERIPIIER IL CIRCULATION IN IICALTIC AND DISEASE their lumina by way of contraction (constric bed is used are largely undependent, more or Lion) of this circular coat of smooth muscula less in their vasomoh se responses 13 2 20 ture and widen their lumina by way of rulara Thus one and the same stimulus may simul tion of it taneously produce constriction in one sascu This assumption cannot be made with the lar lied and dilation in another xule failing Ime ca e concerning vesels of venous type to produce any te ponse in a third "? There, the smooth mu cular coat is thinnes and arranged in a more complicated manner THI MECHANISMIS INVOLVLD IN and the testing of tasonlotion is still more dif VASOVOTION ficult than on the arterial side 1 The question of the cxistence of active In general a response in a target organ vasomotion in the ves cis repre enting the may be elicited in as many ways as there are minute or capıllary circulation which is mechanisms by which the stimulus or stimul devoid of either clastic tissue or muscular ele art comiejed to it Where more than onc ment has been dehated for decacie While mechanism is working at any one time the narrowing or widening of the lumina of mi nel response depends upon whichever of these nutc blood vessels has been observed and dem mechanisms is most active at that time Thric on trated ? the esidence sems to indicate that types of mechanism are known to play sig asomotion here is mediated through a mechi nificant roles in controlling vasomotive re nism that is different from tho e that activate ponses the arteries It appears that narrowing and 1 Neural The best known and most ex widening of the lumina in minute blood ves ten nely studied of these mechanı ms is one sels are brought about respectively by suell mediated bs the ne rious system--through the ing and fattning of the cells comprising the vasomotor neries There are two types of endothelial tube with the role of the cement vasomotor neries the vasocon tractor nerve ing substance to be still more definitely es hich cau e contrachon of the arteriolar mus tablished culature and the vasodilator neries which in Ju l as the structural proce s taking place hibit the former and thereby cause relaxation during vasomotion is different in the three of the muscular rings Vasoconstrictor fibers main parts of the <a cular tree soils physio reach the arterioles by Ino distinct routes logic significance is obuously different If (Todd & Kramer Woollard) through the ellected on the arterial side construction sympathetic fibers of the autonomic nenous means curtailment in supply of oxygen and ystem (which fibers do not extend beyond nutrients while dilation means the opposite the larger vessels of the limb) and through On the venous side vasomotion might be er ympathetic fibers which run with the omatic pected to influence drainage from the part flerte trunks (rachun, the arteries at differ In the minute circulation constriction logi ent levels down to its smallest branches) cally suppresses metabolic exchange while There is good evidence to indicate that va o dilation enhances at constriction is in all probability medrared Since these differences exist concerning through the hberation of an adrenalin like the vasomotive process in the three main parts substance at the nerve endings of the vascular tree various combinations of The sympathetic sasodilators are of two narrowing and dilation may be expected to types tho e which bring about their effect by occur under karying conditions A further the liberation of acct: Icholme (cholinergic complication arises from the fact that the fibers) and tho e who c action is mediated by vascular upply to a specific organ or organ adrenalin uke ubstance (adrenergic system usually responds as a physiologic fibers) The presence of sympathetic vaso unit These units for which the term sascular dılators in the human skin is in dispute --9 art ·15 ET ALUATION OF BLOOD FLOW Chapter 2 Evaluation of Blood Flow ea e The mea urement of rate of blood flow to Pain Important details to look into are an organ or organ sy tem lends itself to many (a) its exact location in respect to the extremi u es the primary one being as an index of the ties involved (b) its on et whether in idious functional capacity of the organ By the same and progressive or udden and acute (c) its token it is u ed to estimate the degree to which character--it may be a di comfort or a pain such function has been affected by certain dis of varying de cription (d) its events which tates or how it may be influenced by may range from an abnormal en ation to certain therapeutic measures whether the lat excruciating intractability (e) the circumn ter be designed preci ely to correct a va cular tances that provoke its appearance—it may derangement or admını tered for other pur follow a traumatic injury or occur in the wake po es of another ystemic di ea e it may be pro Applied to the extremities measurements voked or exacerbated by effort or exerci e or of blood flow are u ed for diagno tic prog it may appear even at ret it may be produced no tie and therapeutic purpo e Various by a suming certain po itions it may appear elaborate methods have been de igned for this at certain time under certain climatic con purpo e each one in turn having been de ditions and (i) the circumstances that bring scribed as accurate and preci e only to be about its relief or alleviation-rest or exerci e shown sub equently to fall hort in one way heat or cold change of position or certain or another of what was expected of it The e drugs In general pain due to sascular dis methods are of con iderable inse tigative in turbances is attributed to anoxia of or the ac terest and will be described in detail but they cumulation of metabolite in the ti sues In have not replaced certain clinical tests and ome in tances it is attributed to neural dis procedures The simple clinical approach that turbances re ulting from interference with the till retains its place in the armamentarium of blood supply to nerves the clinician as well as the inte ligator will be taken up fir t Intermittent Claudication This term has been widely u ed to denote a symptom which CLINICAL METHODS 1 HISTORY AND when pre ent of properly a certained i pa PHYSICAL EXAMINATIO thognomic for arterial insufficiency The clas The clinical hi tory of the condition mut sıcal intermittent claudication is a cramplıke be taken and the general phy ical eramination pain usually in the lower extremitie brought of the patient done with the ame thorough about or intensıfied by walking expecially if nens as with other disea es Vany sy temic done rapidly or by climbing up tairs and dermatologic neurologic and orthopedic dis promptly relieved by re The location of this ea es may manife t them eles in the extremi pain depends upon the res el involved For ties mimicking conditions that eem attribu example occlu ion of the aorta at its bifurca table primarily to va cular di turbance De tron ( Leriches Syndrome ) cau e localiza tailed differentiation in that re pect is not tion of the phenomenon in the hip or hips within the scope of this book the reader is te while the common ite of occlu ion at the pop ferred to the textbooks in the various fields liteal branching produces it in the calf In There are some symptoms and igns which ome ea e the patient complain of pain at must be inte tigated in greater detail becau e rat occurring often in his leep which is re of their association with circulatory di turb hieved by his getting out of bed and ma aging ances The e symptoms include pşın claudi the part Thi indicates a more advanced patho cation fatigue and uch en ory disturbances logic state of the se el in question The a burning numbness tingling and feeling of parallel to angina of effort and angina de cold cubitus 13 striking ·14 I ERIPIIERAL CIRCULATION IV IIEALTH AND DISEASE 50 % part From the differences in morpho cause constriction of the splanchnic se sel logic structure as well as in functional per During exercise there is vasodilation of the formance it might be expected that the three vascular bed in the muscles resulung from lo main parts of the vascular tree also diſler in cal action of the metabolic products formed in their responses to stimuli 1 3 3 the mu cles them chies Cutaneous i asodilation I Physiologic Stimul Changes in en and possibly a reduction in the degree of vironment primarily affect the vascular bed planchnic ia oconstrichon occur as the ever in the skin In general cooling produces vaso 51 C continues 13 Psychogenc fimul such as constriction, while warming produces vasodi anger or fear may cau e cutaneous asocon lation in both arterial and minute vessels striction mediated through hormonal mechan # 56 Heat production in the body and vaso i ms On the other hand embarrassment cau es motor responses in the vascular beds of the the familiar blu h al o mediated throuch cen integument arc governed lry physical, nervous tral nervous pathways Blu hing is cau cd by and neurohumoral mechanisms in such a man vasodilation of the mo t superficial minute ves ner as to maintain body heat within physio ele in the blu h areas of the body notably logic limits When the body is expo ed to ex the face neck upper che t and sometimes on cessie cold increased heal production and the hand and feet Ils occurrence however asoconstriction of the surface ves els occur do not neces llate the pre ence of vasodila Excessive heat production is followed by va o tion of the larger arterial channels and hence dilation of the surface vessels and increased does not indicate an increase in blood flow to heat loss 13 57 9 Deep inspiration causes re the part as a whole Flushing results from pas Mer vasoconstriction of the cutaneous ses cls 13 lle distension of the minute ves els and may In the animal experiments stimulation of the occur when the arterial flow is increased when me entery peritoneum and abdominal viscera The venous drainage is ol tructed or when the is followed by a vasodilator response and fall minute vessel lose their tone Like blushing in blood pressure In patients with ingh tho flu hing may occur without 1a odulation of the racic and cervical transection of the cord dis main arterial channels and increase of blood tension of the urinary bladder and other ab flow to the part may be pre ent without pro dominal viscera evokes asocon triction of a ducing the flush or the blush patchy type in the tocs and fingers and a 2 Pharmacologic Stimuli Various marked vasodilation in the upper trunk shoul drugs have been u ed to produce va omotion der face and neck While there is marked vaso In some of them there is good experimental constriction in the va cular bed of the skin of evidence to show influence upon the blood ses the fingers the blood flow in the vascular hed aels in others such evidence is lacking but of the muscles of the forearm is greatly in clinical experience has proven their useful crea ed In low transection of the cord there 63 A vasoactive drug may produce saso is vasoconstriction in the lower limbs includ dilation in one vascular bed and vasoconstric in the toes and vasodilation above the level of tion in another a drug may be a oactre in the lesion e pecially the fingers * During sleep one part of the vascular tree and inert in an a decreased heart rate decreased car other segment a drug may cause dilation in diac output peripheral vasodilation and re one concentration and constriction in an duced blood pressure In sleep that is di turbed other 63 It therefore appears that the use of with exciting dreams however there is in the terms a odilator va oconstrictor creased heart rate elevated blood pressure and drugs is misleading since these terms would peripheral vasocon friction (1 l'ain evokes a connote a unner al effect Designation of a pre or respon e Thi may be mediated through drug as rasoactie in one direction or the the excitation of psychic centers and the libera other seems possible only in connection with tion of adrenaline by the painful timur 18 specific data as to site and modshtes of its Work and exercise, at their very inception action ness there is or ·EVALUATIOY OF BLOOD FLOW 17 mon motor and va cular disorders and may be their Tho e due to pecific etiologies must be ruled pre enting manifestation In arterial insufi out However if they occur or recur follow ciency blanching is easily indured by eleva ing minimal trauma or if they show no tend tion of the part while in sa omotor disorders ency to heal de pite their apparent mall ize it may be produced by exposure to cold or by or if they present gangrenou changes a so ome emotional di turbance Sudden pallor of called i chemic ulcer with sascular impair an extremty is a common finding immedi ment as the underlying physiopathology must ately following embolic or thrombotic occlu be considered sion of the arterial channel supplying the part Nodules may be felt under the skin in Pallor as part of a generalized condition such patients with polyarteritis (periarteritis no as in various anemic states must of course dosa) There distribution more or less along be ruled out the course of the arteries may be of diagno tic Cyanosis a blush du ky discoloration significance This is established by biopsy of the kin results from deficient oxygenation Nodules of various appearance are een in the of the blood As such generalized cyanosis oc kin (a sa cular tumor) erythema nodosum curs whenever arterial oxygen saturation is (a ensitivity reaction) and several conditions subnormal as in states of respiratory or car not directly related to vascular di ease diac failure I ocalized cyano is on the other Blebs Patients with va cular disease hand sugge is inadequate or slow circulation are prone to develop blebs and blisters because in the part as a result either of vaso pasm or of burns scalds or undue exposure to heat impairment of drainage with local pooling in Alo in areas with moi i gangrene resulting the minute ve els Cyanos13 occurring in vaso from acutr arterial occlusion blistering is com pastic tates is transient In occlusie vascular However patients wath arterial disease disea e it may occur tran ently as part of a sometimes develop blebs spontaneously these equence of color changes---pallor on elevation present very character tic feature well de which persists for the first few seconds on de cribed by Kramer 6 They appear suddenly pendency of the limb followed sooner or later and des elop rapidly usually overnight and by redne s that deepens to a purple hue and is frequently are fully developed when fir i no commonly referred to as rubor on depend ticed As ociation with trauma or the other ency Persistent localized cyanosis as a rule common cau ex is denied They most commonly indicates a more serious or more permanent occur on or about the toes ranging from 1 cm vascular di turbance When a persi ent cyan to 6 cm in diameter The inflammatory reac Osis develops rapidly to a marked degree and 11on is minimal and except for slight itching is associated with coldne s of the parts in burning or minimal pain they are for the volved at usually portends a very grate situa most part ymptomless The fluid content is at tion impending gangrene first clear and colorless becoming turbid and d Shin lesions Lesions due to dermato discolored but not frankly purulent within 21 logic conditions are not considered here Hem to 48 hour after which time a smaller or orrhagic extratasations es petechiae and greater area of gangrene is een at its bae purpura may be seen in acute thromboarters The subsequent course is that of a gangrenous tis polyarteriti (periarteritis nodo a) and le ion Occasionally we have seen such bli ters thrombotic microangiopathy Large cutaneou filled with dark hemorrhagic fluid vgillations at pressure points are not uncom 2 Palpation mon in elderly arteriosrlerotics they have been a The penpheral pulses It is cu tomary called to palpate for the brachial and radial pul es Ulcerations per se do not constitute in the upper extremities and for the femoral prima facie evidence of a cular insufficiency the popliteal the po terror tibial and the dor enile purpura 65 ·10 PERIPHERAL CIRCULATIOY IN HEALTH AND DISEASE Fatigue This symptom may be sery signifi to the branch of the sascular trce apparently cant if it specifically affects the extremities, if involved the arterial the minute or the It is related to effort and of it recurs persist Tenous circulation ently As Aramer®: points out, it may be the first indication of beginning vascular di ease TIF ARTFRIAL CIRCULATIOV Fatigue as part of the clinical picture of a sep temic disorder or due to a neurologic di case 1 Inspection must, of course be ruled out a Asymmetry of the tuto sides The two Burning Numbness Tingling Coldness sides are unequal in the presence of arterio Sensory di turbances usually associated with venous fistulas the ini oled limb being larger than its fellow In one or more dimensions an neurologic disorders are frequentis een in other condition causing undue enlargement of patrents with vascular disease A burning the insolsed limb us unilateral lymph stasis as insation or burning pain may be com plained of by patients with such divergent dis in elephantiasis Limbs surviving arterial oc clusion without the deselopment of gangrene orders as erythermalgia thromboangutis ob diterans or obliterative arteriosclerosis The usually ahow ome muscular atrophy Extra sascular conditions causing asymmetry of the phenomenon however is specially characteris limbs are neurogenic muscular atrophy (eg fic for erythermalgia a vasodilator disorder associated with redness and warmth of the in poliomyelitis) and disu e resulting in de part aggravated by dependency of the extrem crease in size of the hmb or neoplastic condi ity or by application of warmth and relieved tions causing its enlargement by clevation of the part and cold In throm b Condition of the skin and Its Appen poanguitis obliterans and obliteratıse arterio dages In long standing arterial insufficiency sclero is on the other hand there may be some one may note considerable atrophy of the ub color changes but the parti cold to the touch cutaneous tissue Abnormalities of the nails and the symptom of anything is aggravated by (hpyertrophic stunted or deformed brittle elevation of the extremity Justerless) and hair (ccanty thin lusterless Numbness and tingling are common com and brittle) are very common Specific changes plaints but they are frequently overlooked be producing a tight waxy atrophic skin are seen in scleroderma and to a certain degree in cause as an 1 olated complaint they are usu ally attributed to some neurologic disturb haynaud di ea e ances while as an a sociated symptom they are c Color Changes Erythema or redness mo tly overshadowed by pain or burning At in varying shades may be seen in the distal tention ha been called to their occurrence pre parts of an extremity or in some of us digit ceding pain and other signs and symptoms of involung the greater part of an extremity sudden arterial occlusion both upper or both lower extremities or some The subjectue feeling of coldness is very other pattern Purely dermatologic conditions common in occlusie vascular di orders How mu t be considered and sub equently ruled out ever in the ab ence of any other manifestahon Aside from the localization of the finding- 1 ignificance is questionable The part may and whether it is transient or permanent-- even be actually cold to the touch and yet there a ociated symptoms (burning pain etc) the may not be any demonstrahle vascular pathol pre ence of coldne , or warmth of the involved Disappearance of coldne s 083 following part and the conditions that excite or aggra treatment however may be the first indication Sate it (expo ed to cold warmth dependency of an improved circulation in patients with es of the part emotional disturbances) must be considered tablı hed arterial insufficiency In describing the physical findings an at Pallor or Blanching like redne s and lempt will be made to classify them according cyanosis is a very common finding in vaso ·19 El ALUATION OF BLOOD FLOW 44 lated capillaries and angiomata which are marily in the other portions of the sascular benign vascular tumors do not cau e clini tree They do not occur as a result of organic cally significant di turbances in blood flow or functional disturbances in the e ves els proper but merely as a pasaule reaction to TIIE ENOUS CIRCULATIOV hemodynamic forces in the arterial circulation Color changes It has been shown that bar (v13 a tergo) and the rest of the venous sy> ring the naturally occurring pigment the color tem (ws a fronte) of the skin is normally dependent upon the Cyanosis The basic cause of cyano is is amount and color of the blood in the subpapıl subnormal orygen aturation of the blood As lary Venous plexus (a rich plerus formed by mentioned in a presious ection it may be cen the ana tomosis of numerous collecting venules in certain arterial di eases Obviously in se which in turn are formed by the union of ser nous di orders that cau e damming back or eral senous limbs of adjacent capıllary loops) sluggi hne s of the circulation as in venous in tead of that in the more superficial capillary obstruction cyanosis may be a prominent loops ++ An explanation offered for this as the feature the of cour e apples equally to con anatomical fact that the plexus presents a gestive heart failure where there is a general greater area parallel to the kin surface com ized impairment of venous return A benign pared to the capillary loop which are mo tly condition characterized by an inten e local disposed at right angles to at 13 Lexis demon ized cyanosis insolung predominantly the big atrated that pressure applied to the kın pro toe and attributed to verospasm has been duces first collapse of the venous plexus which de tribed 64 in turn causes blanching this is not appre crably increa ed by subsequent compression of Erythema Localized erythema forming part the capillary loops through further pressure of the picture of inflammation, may be seen in It is very likely that the vasomotise capacity phlebitis or thrombophlebitis involung the su of the collecting venules and subpapıllary se perficial veins Thrombophlebitis involung nous plexu es is even poorer than that of the deep reins may not exhibit any superficial ery terminal capillary loop Measuring the gra thema but rather palpable tender cord with dient of pressure in the capillary loop Lan infiltration and edema of the surrounding tis dis68 67 found that this was least in the venous limb the average pressure at that segment be Edema Thi results from the exudation or ing only about half that found at the summit e cape of iluid from the minute circulation into of the loop These findings suggest that vaso the intercellular pace It occurs in the pres motion in the e venules and venous pleru en ence of unduly increased intravascular pres is more or less pa sile in response to the hemo sure increased permeability of the sea el wall dynamic forces at play in the arterial (and or physico chemical di turbances in the com capillary) s tem as well as in the rest of the position of the blood Localized edema occurs senous tree Hence they di tend whenever following senous ob truction primarily be the arterial inflow erceeds the venous outflow cause of the resulting congestion and increased and collapse when the reverse takes place intras ascular pres ure and in all probability reflecting to a certain degree the vascular sta also from increa ed vascular permeability tus of the part observed Lymphedema is a brawn, infiltration of the in It hould be noted in view of the above that tercellular spaces due to lymph tasks following by and large pallor or blanching redness or obstruction of the lymphatic channel In erythema and cyanosis though manifested longstanding senous obstruction especially through the initial segments of the senou sys that involving the large senous trunks lympla tem actually reflect only the pathologic and tasis is superimpo ed on the edema ooner or Thysiopathologic responses taking place pri Jater sues ·18 PERPUFAAL CIRCULATIOY IFALTI1 AND DISEASE The salis pedis artery (or its proximal part, the un la o pastic and in occlusie vascular de or anterior ubial) in the loner extremitie ders occurring transiently in the former and presence or absence of pul ation and its force persistently in the latter Aside from concom fulness are noted the presence of sclerotic mitant color changes there are usually asso changes by the hardnes elasticity or beading ciated symptoms of vascular insuficiency of the arterial wall 15 ascertained The pres Coldness of one extremity or parts of it, ence of strong pulations indicates adequate cvaluated best by comparison of it with the main stem or primary circulation at the point other side, is almot invariably a manifesta of its detection Its complete absence may in tion of vascular pathology which may again dicate an embryologic anomaly or malforma be either vasospastic or occlusale in nature tion or an obstructive process involving a one being distingui hable from the other by proximal egment of the primary arterial the associated signs and symptoms channel We are using the term primary ar Varmth as a localized physical finding by terial channel adusedly instead of referring and large implies the presence of inflammation to the regional circulation as a whole Com In uncomplicated obliteratne vascular condi plete absence of a peripheral pul e even if re tions despite an assoriated finding of redness sulting from obliterative arterial disease is no or erythema and the complaint of a burning absolute gauge of the adequacy of the over all sen ation, the involved parts are cold to the circulation The primary arterial channel touch in these ca es warmth or heat indicates may be blocked but there might be sufficient an inflammatory reaction to a complicating sec econdary or collateral channels to maintain ondary infection an adequate blood supply to the distal pirts Pe The only ra cular disturbances exhibiting riodic disappearance of the pulse is character abnormal warmth in the involved parts in the isti of vasopastic atates Diminution in force ab ence of inflammation are arteriovenous fis fulness of a pul e previously noted to be nor tulae and erythermalgia the latter character mal is usually indicative of a developing ar ized by usually bilaterally and symmetrically terial obstructive pathology The permanent warm red and burning extremnities disappearance of a previou ly palpable pulse is a diagnostic feature of embolic or throm 3 Percusion and Auscultation bolic occlusion An abnormally located pul a The e methods of physical examination are tion may he lelt over well developed collateral very rarely u pd in the detection or evaluation vesels when the normal primary channel is of asrular pathologic conditions An excep ob fructed An abnormally located pulsation tion is the confirmatory finding of a bruit or associated with a thrill a bruit and/or a mur murmur on auscultation over the su pected mur is a common finding over arterio venous site of an arteriovenous fistula or an aneu fistule if the e are encountered over a ma s rysm whuch al o exhibits pul anle expansion they THE MINUTE CIRCULATIO are almo t pathognomonic for an arterial aneurysm Petechiae and I urpura Minute extravasa b Changes in Surface Temperature Cold tions of blood may ocrur as a result either of nes, of extremities if bilateral and symmetri embolic phenomena infectious or noninfec cal may be a normal finding Esen marked trous or capillary wall damage (defect in in tercellular cement substance) While the e le coldnes may be an expre sion of a primarily sions may occur in pathologic tates where neurologic rather than a va rular disturbance there is a va cular di order they do not nec In these cases aside from the di tribution and es arily reflect the extent or the magnitude of the absence of symptoms there is often as o That disorder ciated hyperhidrosis On the other hand bi lateral and symmetrical coldness may be found Telangiectasias which are abnormally do ·EVALUATION OF BLOOD FLOY 21 ing of the selected rein the limb is lonered moment when intra arterial pressure equals to the horizontal position and the time for re the applied pre ure This can be detected by filling of the elected vein is noted Normally the appearance of an au cultatory ound with this tales 5 to 15 seconds a delay indicate each pul e wave over the portion of the ar impaired arterial inflow Obu1ou ly the te ters ju di tal to the obstruction when the cuff as de cribed as of no value in the presence of is lowly deflated The value of the applied varicose veins with defective vale and venous pres ure at the first appearance of a ound in ufficiency due to consequent backlion of I taken to be equal to the systolic pres ure blood However where the defect as limited On further deftation of the cuff the ound to the superficial et of seins (not involving change in character and finally di appear This the deep et or the communicating seins) the end point i recorded as the dia tolic pres ure tent may will be of value of the backflow of Steele s ba hown that this be t approximates blood is presented by placing an easily re the directly recorded dia tolic pres ure The movable rubber band around the ler lut be direct method is uperior as far as objectivity low the knee before the limb is lonered in and accuracy are concerned However for order to occlude renous circulation daily practical u e the indirect method , per fectly adequate e Reactre hyperemia test The limb to be te ted is eles ated until the sex els are emptied & Radiography Aortography and Artenog of their blood content a evidenced by maxi raphy With plain radiography the presence of calcification in vacular walls v ualized mal blanching produced (this i bel appre Thı procedure alone however does not prociated on the palmar or plantar surfaces) A vide the examiner with any information as to cuff or tourniquet is then placed high on the limb and pres ure above the stolic is ap the patency of the e vessel the presence or ab sence of ob trucne pathology or the pre ence plied to occlude arterial circulation The limb (let alone extent) of compensatory collateral is then lowered to the horizontal level and the channel Vore information hoseier includ pres ure relea-ed The time it takes for the blu h (reactive hyperemia) to occur is noted ing that concerning the exact ite of the ob truction may be obtained through the u e as well as the time it takes for the normal color to et in A more elaborate te t utiliz of radiopaque sub tances The e are injected ing thus principle is de cribed by Pickering percutaneou ly or through a cut donn into the arter then visualized radiologically as The arterial pressure Direct measure they course through the various arterial ment of arterial pre ure in ohes the intro branche The ub tance may be injected into duchon of a medium ized needle into the ar the aorta (aortography) or into the maller terial lumen the sy tolic and dia tolie pres arterial trunks (arteriography) Various sub sures are registered by a manometer attached tances have been employed for this purpo e to the sy tem There are a number of in tru Diodrat leo lopax and Swedih Umbradıl ment available that permit direct recording have been found mot at factory of the pres ures The indirect method using the phygmo TESTS FOR THE VIVUTE CIRCULATION manometer (Raya Roccı) 13 ba ed on the prin a Postural Color Changes and Reache ciple that the pressure necesary to suppress Hyperemia While po-tural color changes and flow in an ela tic tube is about identical with reactive hyperemia are u ed as gauges of com the pre ure under which flow through the ses petency of arterial channel the reaction ac sel occurs A pres ure cuff is placed around tualls ob erved a previou ly mentioned con the limb and inflated unul interruption of flox Ils in changes produced in or reflected by through the artery has been a certained The the minute circulation In a broader en e point at which blood flow is resumed is the therefore wherever uch a te t can be per ·20 PERIPHERAL CIRCULATION IN IEALTII AND DISEASE Varicose l'cins Varicosities of the superfi blanching may occur on elevation this will cial seins are essily seen and palpated as prom give way to normal color within 30 seconds inent, engorged and tortuous worm lıke on dependency In the patient with arterial in structures just beneath the overlying lin but sufficiency, return of normal color on depend rared heyond its level Varico e seins are ency is either coneiderably delayed (1 minute Usually the result of congenitally real values or more) or the pallor is immediately replaced and vessel wall incompetence of the sales of by rubor, as described above the deep and/or communicating veins or the b Postural Pain This iſ present accom presence of arteriovenous fistulae, they may panies the postural color changes With eleva represent extensive collateral channels follor tion of the lumb the action of gravity further ing obstruction of main senous trunks depletes the already insufficient arterial blood I aricose or Stasis Ulcers Findings char supply to the part causing the blanching pre acterizing these ulcers are aside {rom their ulously described and at the same time pro indolence and resi lance to treatment, the se ducing pain quelae of prolonged venous stasis increased c Changes on Ercrcise Il the patient is ly pigmentation edema and often the presence ing on his back with his limbs elevated he is of uperficial varico c vein These ulcers are made to everu e by alternately flexing and datinguished from ulcers due to specific ertending his ankles and toes (or wrists and causes trophic or pre sure sores and schemic fingers) 10 to 60 times per minute Blanching ulcers ( plantar ischemia test )" and pain increase in the presence of marked arterial insuficiency CLINICAL METHODS 2 TESTS AND while in its alence or in well compen ated PROCEDURES cases normal color may be restored through There are numerous clinical tests and pro exercise cedures that are employed to determine the Claudication Time The patient is made competence or adequacy of the circulation in to walk at a regular fa t pace (120 steps/min) the extremities Some are very simple while or to chumb a Night of stairs until pain or others are relatively complicated the ease or claudication appears The time that clapsed difficulty of their performance being no inder (rom the start of the te t to the appearance of their relatie clinical u efulness These pro of the pain is noted as the claudication time cedures will be described briefly grouped ac A treadmill or a physiologic bicycle have been cording to the portion of the vascular tree they ued for the same purpo c are intended to test Claudication Distance The test is per formed ac above except that the di tance TESTS FOR TUF 4RTERIAL CIRCULATION rather than the time before claudication oc curs is measured as a criterion a Postural Lolor Changes 68 70 Characteris tic color changes may be produced at will in Lisch Test Again either claudication limbs with arterial insufficiency with the pa distance may also be determined tient lying on his back elevation of the leg and with the patient lying flat on his back and ever loot produces blanching of the part best appre cising the limb from this position by rhythms ciated on the plantar surface of the toes and cally flexing and extending the extremity at a the soles of the feet When the patient sits up rate of 30 times per minute with his feet dangling down the side of the bed d 1 enous Filling Time? One of the promi she rallor 1» sooner or later replaced by a red nent superficial veins on the dorsum of the dish or purplish erythema that may be diffu ed foot is watched carefully With the patient in or moftled in appearance in normal per ons a supine po ition the limb is elevated to drain with unimpaired artenal circulation, slight the veins of their blood content After empty time or ·23 FVALUATION OF BLOOD FI OW roundin, Nare and wheal formation The red re ponses This concept assumes the presence reaction is a red band which appears shortly of a neuro humorał mechanism with hrta (3 15 econd) after stimulation on the line of min lile sub tances respon ible for the red troke Pale lines on both sides of the red reaction and wheal production by direct action band may also he een Both reactions appear on the capillary wall and acetylcholinere to result from direct timulation of the rapıl lea ed by the excitation of the aron reflex re lary wa]which cau is dilation of the se sel sponsible for the artenolar dilution that causes where the mechanical timulus was greater the fiare and ron trichon where the stimulation was less & Salıne If heal Test When physiologic inten e Their appearance is not dependent saline olution (02 cc of 0 83% olution) is upon nervous mechanı mis or the tatus of the injected intradermally a wheal is produced at larger va ular channels If the stimulus is the sile of injection Normally this wheal dis greater in intensity or is applied repeatedly appears in 30 to 60 minutes It has been dem a fare or a preading fluh tarts to surround onstrated that in the presence of vascular the local red reaction shortly alterward it 19 di case there is ronsiderable reduchon of the outla ted by the local reaction The fare te di appearing time 83 95 A Man in this test is sults from arteriolar dilatation due to an axon the need to make multiple inoculation sites--- reflex et in motion by the stimulus Occlusion a very inconvenient procedure for the patient of the arterial circulation presents the orcur Evaluation of the te is actual significance as ence of the flare Upon still more intence or difficult because of the many nonva cular fac repeated mechanical stimulation a blanched tors influencing absorption and raised lesion appears at the site of the Ted reaction completely replacing it (wheal TESTS I OR THEE VOUS CIRCULATIOY formation) The lesion at first harply de marcated from the surrounding normal skın a Postural Changes in the presence of ve oon spread out and decreases in height grad nous in ufficiency resulting from deep venous ually disappearing after a few hours The occlusion with or without sarico ities swelling wheal results from a loralized increa ed per or edema of the extremity is produred or ex meably of the capillary wall and als produc acerbated by dependency and relieved by ele tion is not dependent upon a nervous mechan vation of the part Similarly pain that is usu ally characterized as a dull ache or a heaviness I en is has demon traled convincingly that may be experienced on dependency of the part this triple se pon e results from the produc or after prolonged standing Relief is obtained tion of a histamın like substance by the under by recumbency or elevation of the part lying cells The action of these substances is 6 T'ests for I enous Insufficiency (Presence (ery similar to that of hi tamine which al o of block or of incompetente) Localızed ve produces the triple response when injected nous insufficiency results from obstruction or intradermally This production of an H like narrowing (secondary to thrombophlebitis) has similarly been invoked to ex or from weakened vascular walls or incompe plain the cutaneous reaction ob eryed follow fent valses (main cau es for the development in, various physical stimuli such as burning of varicosities) These pathologic conditions freezing electrical stimulation etc as well as may invoke either the deep or the superficial tho e which compri e the cardinal signs of in reins In the presence of superficial varicose flammation This is al o true of the cutaneous veins localization of the exact source of venous le ions ob ered in disturbanres of the pos bach Row 13 nece ary in the deep venous sys terior or sensory root of the central nervous tem varices hardly occur but incompetency of ystem (via antı dromic impulses) 91 They are the sales may be encountered the most fre con idered the basic la cular lesion in allergic quent cause of insufficiency of the deep veins is Ism sub tance ·22 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE f formed at all the capillary system must be fisualization of capillaries and the blood flow adequate or competent through them by opaque illumination with b Capıllary Pressure A method to meas a strong light under a micro cope (Lom ure blood pre sure in induidual capillary bard ) 78 The capillary system may be thus loops by micromanipulation inserting a glass ssualized at any place in the integument in canula into either of als bmbs has been de cluding the acce yıble mucous membranes (lip scribed by Landis" Ht reported changes check guma conjuncinya) The number site in capillary pressure produced by altering the and configuration of the loop the relation distance (lesel) between the heart and the res hip between its arterial and venous limb sel being examined the application of hea! the velocity and character of the blood stream Venous conge tron production of a histamine through it and the response to the various flare application of cold and in Raynauds stimuli may best be ob ered at the nail desease"? This procedure does not find clini bed where the individual loops are long and cal application becau e of the need for sery run horizontally The conjunctn al capillaries specialized apparatus and technical skil} in may likeni e be observed with the u e of the direct methods using a micro capillary tonom lit lamp microscope The po silubpes of this eter measure either the amount of pressure procedure as a diagno tic tool are question that empres or the pressure that permits reſi}} able despute reports in the futerature de crib ing the capillary loops as observed under a ing abnormalities in the capillary loops as o capillary microscope cated »ath Tarjous diseases 8 Consequently m pite of its relative simplicity the procedure c Capıllary Resistance Rumpel Leedes has not found the clinical application it pos test & tourniquet or a sphygmomanometer sibls descries becau e a bass of correlating cuff is placed around the arm and positate the sometimes intriguing morphologic sarra pressure to obstruct venous return is applied trons with known clinical entities as practically midway between the systolic and diastolic nometr ten! pressures for 10 minutes The number of pe techiae appearmg in a selected area distal so e thstamine Flare 44 87 90 When histamine The obstruction (usually in the forearm) (i 1000 acid phosphate solution) is price poled The degree of capillary rest lance is or injected (01 cc) intradermally a wheat taken to he inier ely related to the number and a surrounding fare dei clops at the site of petechiae produced of inoculation The reaction is prompt begin Hecht Dalldorl s te ! In this procedure the ning in 2 minutes and ending within 10 min production of petechiae a induced by the ar utes A delayed or poor development of the re plication of negatne pressure to the skin This action has been interpreted to signify an im is done by means of a vacuum pump connected paired circulation in the area te ted Since to a small «uction cup that is applied to the the wheal results from a direct action on the kin for one minute Capıları resistance 13 tapıllary wall while the flare appears to resuhi measured and expres ed in terms of the least from arteriolar dilatation produced through negale pressure required to produce pe an axon reffer the wheal 19 more significant techiae Thus leat can be vers easily performed than the fare in ses of the fact that the pro *ith a petechiometer a simple apparatus con duction of the latter may be influenced by the sisting of a bell connected with a suction syr pre ence of ome nerious di order ange arrangement Attempts to quantitate the f Lexus Triple Response * If the kin is test have not met with impre ene success troked firmly with a pointed in trument the d Capıllary Miscroscopy A drop of cedar following reactions mas be eliciled degend oil placed on the kin renders the surface ho ing upon the intenssty of the tumulus a red (vasodilatron) folloned by a sur mogeneous and tran parent enough to permit IS reaction ·25 EVALUATION OF BLOOD FLOW walking alone (without the tourniquet) is also into the veins in a number of ways In Indirect observed At those levels where application of phlebography it is injected into the arterial the tourniquet followed by exercise is not as trunk supplying the extremity roentgeno sociated with appreciable change in the filling grams are then taken at short intervals This of the veins it is presumed that the communi method is theoretically the best but technical cating and deep veins are incompetent difficulties and sometimes unpleasant side ef fects are associated with it A simpler proce | Determination of Venous Pressure Ve dure is to inject the contrast substance into nous pressure may be measured directly by in troducing a needle into the vein and connect the venous system (direct phlebography) with ing it to an upright manometer The vein se a tourniquet applied to occlude venous return lected for the procedure must be placed at the in the investigated extremity Because of the same level as the right auricle if this is not generalized distribution of the injected sub stance and despite the tourniquet visualiza possible or impractical corrections for the level difference must made in reading the tion is sometimes poor Acute thrombophle results Venous pressure is usually expressed bitis is a contraindication to phlebography The contrast medium may also be intro in centimeters or millimeters of water the nor mal range being 60 to 160 mm 101 103 duced directly into dilated superficial or varı Indirect mea urement of venous pressure cose veins The high concentration of the sub can be done with the use of more elaborate in stance and the presence of venous stasis in the struments 104 10 On the other hand very area make the ves els stand out beautifully simple bedside procedures205 yield fairly good Varicose veins due to incompetence of the approximate values With the patient lying on superficial set alone may be differentiated his back the hand is lowered below the heart from those due to deep venous insulficiency by level to fill the veins on the back of the hand phlebography unless there is incompetency The hand is then gradually raised until the of the deep and communicating veins they can verns-being carefully watched-collapse The not be visualized by injecting the contrast me vertical distance reached between the dorsum dium into the superficial varicosities 107 of the hand and the level of the right auricle SPECIALIZED METHODS OF gives a good estination of venous pressure MEASUREMENT Venous pre sure can also be roughly esti mated by observing the veins on the undersur Some of the follwing tests and procedures face of the tongue These are normally col which are designed to measure and document lap ed when the subject is standıng or sitting the behavior of the general circulation as well but are distended if the venous pressure is as the physiologic respon es of the circulation higher than 200 CD water 13 in the extremities are useful tools in investiga tive studies Since their performance requires & Venous I usualı ation The veins may be made to stand out and be visualized readily the services of specially trained personnel and if a fluorescent substance is injected intrave theu e of complex apparatus these procedures are rarely done in clinical practice Good nously and the limb observed under wood light clinical examination will suffice in most in Exposing the limb to an infra red lamp will stances to arrive at a definitive opinion as to al o make the veins readily yışıble With in fra red photography a picture of such veins diagnosis and management may be taken GENERAL CIRCULATIOY k Venography The venous system roay be a Cardiac Output Changes in cardiac out visualized radiographically As in contrast ar put are necessarily reflected in the entire vas teriography Diodrast is commonly employed cular tree here there is impairment of ar The radiopaque substance may be introduced terial circulation as in obliterative vascular ·21 PERIPHERAL CIRCULATION IN IIFALTIC AND DISEASE partial or complete obstruction as a result of remain empty then the defcct insolies either thrombophlebitis The resulting congestion or both of the superficial segment The tourni may cau e insufick ney of the values of the quet placed lugh around the thigh (or the pres communicator, vans or thu production of col sure applied on the great saplienous icin) is lateral channe! Either condition may in then released If the veins remain empty, the turn cau superficial varicose veins that are great saphenous lein is competent If they fill grossly indistingue liable from the ordinary the great sapheneous iein is the source of back run of the mill variety which arise from con flow If the veins remained empty even after genstally delective values removal of the tourniquet, but filled alter re Various clinical procedures may be u ed to mos al of the pressure applied at the small sa determine whether the varicosities were formed phenous vein only the latter vessel 13 incom as a equela of deep enous disease or if they petent are of the congenital variety The following Filling of the veins upon releasing the pres lests are commonly used to evaluate the situa sure on the great saphenous vein necessitates tion in cases of venous insufficiency a third performance of the procedure When clodified Brodie Trendelenberg Test 86 87 the patient stands up the tourniquet is re Rath the patient lying on lus back, the leg is tained but the pressure on the small saphenous clevated to empty the veins in the extremity sein is relca ed I the cins remain emply The patient is then made to stand up and the the incompetence is localized in the great veins are ob erved closely the examiner noting saphenous sein, if they fill both the small and the rapidity of fillin, (filling time) as well as the great aphenous veins are incompetent the direction of filling whether from above or d Perthes Test - A rubber tourniquet i below Normally the veins should fill slowly applied around the thigh with sufficient pres from below Filling from above indicates that sure to occlude circulation in the superficial the valves are incompetent Roughly slow fill veins The patient is then made to walk about ing from above--where the column of blood the room If the dilated veins diminish in could be followed as it backflows into the pre size, it indicates that the communicating and viously emptied veins-signifies that only the deep seins are able to compensate for the in superficial ve sels are involved Rapid filling sufficiency of the superficial venous sets of the veins--where the source of backflow e Other Tourniquet l'ests op 100 Incompe could not even be localized-indicates incom tent communicating reins may be localized by petence or insufficiency of the deep or com modifications of these tests The Trendelenberg municating eins test is done but after the veins have been emp The procedure is repeated and the veins tied the tourniquet is applied at various levels emptied With the leg stilt elevated a rubber of the thigh and les before the patient is made tourniquet is placed high around the thigh or to stand The defective yes el is indicated by pressure applied with the examiners fingers the highest level where application of the tour to occlude the great saphenous vein as it emp niquet is followed by filling of the vein when ties into the fu moral sein at the region of the the patient stands up The use of multiple tour fossa ovalis At the same time the small sa niquets to prevent backflow from proximal su phenous vein is occluded by digital pressure perficial vessels or from other deep or com as the vessel drains into the popliteal ycin in municating eins may yield even more specific the popliteal fossa The patient is made to information stand up with the applied pressures main In a modification of the I erthes Test (Ma tained If the varico e reins result from in horner and Ochsner) the tourniquet is applied competence of the deep or communicating at various levels of the thigh and leg and in each instance the effect of walking on the varı veins they fill de pite the applied occlusion on the great and small saphenous seins If they cose seins is noted The effect of exercise or ·ETALLATION OF BLOOD FLO11 27 ARTERIAL CIRCULATION useful in providing the examiner with » val o Oscillometry and Oscillograph, 131 138 esidence of the progress of occlusile vascular This method of examination is ba ed on the di ea e It can al o be useful an demon traling principle that iſ optimum pressure (usually the reopening of occluded oniginally primary between 80 to 130 mm Hg) is applied through arterial channel if this should occur in the a cuff placed nugly around an extremity the cour c of therapy pul ations of the underlying arteries Bre trans 6 Calorimetry "10 14+ The circulation plays mitted to the enclosed air in the cuff B1 con a con ide rable role in the regulation of body necting the cuff to a delicate needle arrange temperature la odilatation of the surface ment the pulations are magnified and may be ve sels increa es the vascular area expo ed to Lualized as oscillations of the needle in front the external environment promoting heat lo s of a dial or recorded on a moked drum or by radiation Vasoconstriction does the oppo tracing paper The amplitude of the observed oscillations has been taken as an index of the site Thus there appears to be a direct relation ship betneen heat loss from a body surface and adequacy of the underlying large arteries the vascular status in the same area On the Hence diminished pulsations down to zero basis of this ob ervation blood flow was esti reading“ were interpreted as indicatne of im paired and insufficient circulation suggesting mated by mea uring the heat loss of an ex tremit This was done by immersing the ex the presence of arterial di ea e of either spas tic or occlusııe nature tremilies in water I clow skın temperature and Erroneous interpretations of the results ob calculating tlir leat loss from temperature Cained with the procedure and st« unarlerguary Clintsta obra rsrol in the water as measured to quantitate blood flow (dur to the impneul il Thirst An A tumler of arrested objertions ity of calibrating the apparatus) have lerns 10 Din melhor Mor lar arsimylion that the pointed out repeatedly by various workers in Hardli. the only course of lirat ignoring the the field One can fully after with the statr fart that lipat la frnorated for example by ment that the procedure is u rful only for se for murular ti *15* I* rodently arroneous cording pulations in the extremities for future reference and for trarhing phrpo es Furtherine ir ilir Aumption that the arcrage other temperaturn of thor walrs in thr calorimeter wise it is one of the Ira t salual le of all meth mavle takrn author trmprrature of the sonous ods of inse tigation of the peripheral circula LLOd 15 arrestat lr only within narrow limita trong si Finally thor Irmfrsaturr changes ob The phyical limitations (f the procedure for obviously reflect chungrs taking place make it unable to indicalr the prerenre or ab in the I lood only within aufrrficial pole sence of circulatory insuficiency (whirhistest (kin) while changes in the I loodal sortioned appreciated by the rearnting of cliniral mani to the deeper ty sims are hardly arrunted for lestations) and unreliable as a measure of arte There were m rroset many trchnical difficul tial blood flow The anumaloys curs of even ties insolved in the method which made its use medium ized eup-firial artering the presence img rartical and with the difficulty of inter of thick ukrutanrru gads in ofese individ preting its pr*alls it was di raided until se uals and the prepare it will developed but seats isesed by vlen llowicz is who modified non pu! atilo email arterial collaterals ade the method without entirely eliminating the quately componenting tre treally or partially caur for objetion occluded frimary artrosal channels may reader poor or aterpt r all metnir sradings meaning c Surface Thermometry Based on similar deliberationa thna that led to the calorimet less in the evaluation of the circulatory ifua TIC Erthod, change of urface temperature ja various areas mere obverted, torz ured and Sequential willowjaphy may however bu lion "139 tion ·26 1 ERII ECE RAL CHICULATION IN HELLTIS AND DISEASE it is pre disease a decrea e in cardiac output may drug (which acts in the carotid sinus stimulat prose critical in producing arterial insufli ing respiration) is injected (0 23 to 0.5 ml of ciency and its sequelae On the other hand, 2% solution) into the antecubital vein and some vascular disorders artcriovenous the time recorded with a pneumograph and fistulae are capable of influencing cardiac out stop watch put directly cren to the extent of provoking The 'normal values vary a little with the heart failure different methods employed The arm to luno There are various methods to estimate car time (using ether) averages 6 seconds (3 to 8 diac output The principles involved the math seconds) The arm to tongue time (saccharın cmatical calculations required and descrip or decholin) averages 12 weconds (8 to 18 sec tions of the methods are readily available in onds) The arm to arm time (radio active the literature 18 109 117 substances) averages 7 seconds (2 to 14 sec b Circulation Time 118 1.2 The shortest onds) The pulmonary circulation time (ra time required for blood to flow from one dio active substance or sodium cyanıde) aver point in the vascular tree to another is referred ages 11 seconds (7 to 14 seconds) With these to as the circulation time of these points values the speed of blood flow in the systemic Having established normal values and pulmonary circuits may be estimated sumed that a prolonged or increased circula c Circulating Blood Volume Any change tion time indicates a slow flow of blood while in circulating blood volume may influence pe a shortened or decreased circulation time in ripheral blood flow and in turn be influenced dicates a fast or short circuited flow of by peripheral vascular disorders The various blood Using a systemic vein eg the ante methods used are described in the litera cubital vein as the starting point, an indi ture 117 120 180 calor substance may be injected intrare d Blood Coagulation In certain wascular nously and its presence detected at desired diseases where there appears to be some asso end points like the lungs and the tongue ciated disturbance in the clotting mechanism measuring respectively the arm to lung and of the blood (eg recurrent thrombophleb! the arm to tongue times In the first in tis) studies of the various factors involved in stance ether (O 25 ml ) may be used the end blood coagulation are indicated By and large, point being indicated by the coughing reflex such simple procedures as the determination induced by the excretion of the drug in the of bleeding coagulation and clot retraction lungs In the second instance decholin (3 5 times are adequate for screening purposes ml of 20% solution) or saccharin (25 Cm Abnormahres in any of these values call for in 4 ml of water) may be used the end point a more thorough hematologic work up and the being indicated by the production of a bitter performance of other tests including the de taste (or sweet taste) in the tongue The dif termination of platelet count red cell fragility ference between the e two times is the lung blood Ca Vit a plasma fibrinogen prothrom to tongue time There are also methods1 31 bin time prothrombin consumption time plate designed to measure pulmonary circulation let adhesiveness heparin tolerance plasma an time One of these is to introduce a radioactive tithrombin activity and others substance (radium or Na ) into an antecubital e Angiocardiography The intravenous in Tein and to detect its arrival at the right ayrıcle jection of a radiopaque substance that permits and at the brachial artery at the opposite side the radiologic visualization of the individual with a shielded Geiger Mueller counter The cardiac chambers is very useful in the study of difference between the arm to arm time and various congenital anomalies and valvular le the arm to heart time is a fairly good measure sions of the heart which may be associated Another with congenital anomalies or secondary of pulmonary circulation time changes in the peripheral vessels method is to use sodium Cyanide where the ·29 EVALUATION OF BLOOD FLOHY Te ents the rapidity of arterial inflow per unit ities the patient is made to clench the hand of time or the rate of blood flow into the part againt a fixed resistance (provided by examined This rate is usually expressed as springs) keeping time with a metronome To milliliters of blood per 100 milliliters of tissue test the lower extremities the patient is made (the volume of the enclo ed part duided by to fier and extend the foot at the ankle either 100) per minute Yoluntanly (synchronous with a timing de The medum ued within the sjat m may be tice) or by elertrual stimulation Variation in water or air The type de cribed above is based re istance to exerci e is usually accomplished on air displacement If this method intended with springs or weights An electrically pro to evaluate blood flow to an extremity, is ap pelled treadmill or a phynologic bicycle has plied to a digit (finger or toe) or hand or foot also been used for the purpose The time that the behavior of the circulation in the whole elap ed from the beginning of exercise to the Imb cannot be well judged because of the ana time when pain appears is noted as the claudı tomical fact that the toes and fingers and calon time On the ergograph the force (am hands and feet are (exception made of the plitude) and duration of muscular contraction bone) mostly in with only very small muscle may be ricorded and claudication time as well mass while the opposite is true for the rest of as fatigue time graphically demonstrated the extremits We have ascertained that the | Determination of the 0.x) yen Content of skin/muscle ratio is about 03-05 in the Peripheral Blood The amount of oxygen taken forearm and lower leg and 45 in the hand from the blood as it pa e through an extrem and feet 101 l'esults obtained with a large part ity has been used to determine the adequacy plethysmograph 101 which permits the study of of circulation to the extremily Oxygen con the whole foot foot and leg hand or forearm sumption determined from the difference in and hand are obulously more representative oxygen content of the arterial and venou measures of blood flow to the extremily Fur bloods in the extremity ( arteriovenous differ thermore because of the anatomical fact that ence ) 16 The u efulne s of the te tas limited (exception made to the bones) the hand and by the fact that 0 saturation of the blood is in the foot are mo fly kan while the leg and fore fluenced by various extravascular factors and arm are mo tly muscle by determining blood the normal wide variation observed in venous How in these large parts (blood flow to the leg oxygen saturation even under constant envi 13 computed from the difference of the values ronmental and phy sologic conditions An derived for the foot and the foot and leg) ory meter attached to the kın has been con the valves obtained may be broken down tructed u ing color differences picked up by lo estimate separate skin and muscle flows in a photoelectric cell 169 The method is rather the extremity with more reasonable approxi crude and hardly ments quantitation it also mation As Alter, Barker and lines posat out is dependent upon many non ascular factors the method a hardly applicable in ordinary such as thickness toxlure and other qualties clinical practice but we find it a mo t aduan of the skin Since it is ved in blu h areas tageous method for investigation of the physi many elements enter that bear no direct rela ology of the circulation and of the many tionship to rate of blood flow An apparatus methods now available double-s the bet called the oxygen electrode 10 ems to be a the above mentioned authors have tated 139 much more promising its use is all in the e Ergograph, 105 180 The u e of the er experimental tage however it can lived at gometer and the ergograph (equipped with re varying depth and it appear to be by far the cording facilities) is ba ed on an attempt to mo t accurate indicator of consumption tandardize the determination of claudication 31ailalle Bł pre ent for tissues of the extremi time as an inder of blood flow to the mu cle tes bed of the extremity To test the upper extrem 8 Use of Radioochie Substances Sodium ·28 PERII IFRAL CIRCUI TIOY IY HEALTH AND DISEASE lor 149 u ed as indices of blood flow lor this purpose culatory status in the decper vascular beds various in truments and apparatuses have especially the muscles Finally sympathetic been devi ed including the Dermatherm 1410 denervation of a limb fixes its surlace tem the potentiometer indicator 17 the Rubicon perature at a certain level (which persists for skın temperature measuring device the elec as long as regeneration of the severed nerves tromolist thermometer and the Derma has not taken place) making the limb incap able of exhibiting changes in cutaneous tem By and large there is a defimte correlation perature despite changes in blood flow in re between a limb s surface temperature and its sponse to even powerful va omotor stimul: 151 vascular status As mentioned previously yas d Plethysmography If the rate of venous cular impairment as a rule is associated with return flow to a limb or organ were to remain coldne s of the part involved While isolated constant or if it can be momentarily sup temperature readings may not give any defi pressed, the character of arterial inflow to mite information significant temperature dif the part is reflected by changes in volume of ferences between homologous parts of two er the part Qualitatively an increase in volume tremities and in abrupt changes in those of of the part implies an increase in blood Nou adjacent parts of the ame extremity are in to the part and a decrease in volume of the dicative of vascular disturbance Such differ part implies a decrease in blood flow Quanti ences may often be detected simply loy the tatuely the rate of blood flow (increase or palpating hand without the u e of any appara decrease) may be determined by the rapidity tus and may even yoeld very useful informa or acutenes of this change in volume A num tion On the other hand the use of elaborate ber of plethysmographic methods? 163 have instruments to make the determination of tem been devised to measure blood flow all based perature differences and changes may lead to on the above mentioned principles ici In gen erroneous conclusions of the value obtained eral the part to be cvaluated is enclosed in an are unqualifiedly taken as a measure of blood air tight and leahproof box or compartment flow to the extremity As experience accumu which is connected through a nondi tensible lates the limitations in interpreting surface tube directly to a recorder A train gauge or thermometry as a mea urement of total blood other electronic device may be interpo ed flow to the extremity become more and more Changes in pre sure inside the plethysmograph evident box (cau cd by volume changes of the part of The extreme lability of surface temperature the limb in ide it) are then converted by the in the upper extremities in line with the lat strain gauge into electrical impulses which ter function of minute to minute adjustments are amplified and recorded in an attached dı to slighte i temperature changes in the internal rect writer by the induced excursions of a and external environment on the one hand and heated stylus Occlu son of the venous return the relatie luggisles of re pone in the flow from the part is accomplished with a cuff lower extremities (bung called upon to react applied around the part ju t proximal to the only in re ponse to eros environmental tem plethysmograph This cuff is connected to a perature changes or to stron, vasomotor stim pressure re error with facilities for sudden uli) on the other makes the interpretation inflation of the cuff to a pressure al ove le of cutaneous temperature changes in either nous ptes ure but below diastolic arterial pres Jimb as reflecting total blood flow to the part sure If the change in volume of the extremily rather questionable Furthermore (following sudden sonous occlu ion) as reg face temperature may logicall; be expected to tired by the prcur ions of the recorder stylus reflect changes in the vascular bed in the skin is recorded on EKG or other suitable paper this does not necessarily mean that it likewise and run according to a et timing device the reflects (in magnitude or in direction) the cir slope of the resulting curre (flow curve) rep 0 while sur ·31 EVALUATION OF BLOOD FLOW Changes in temperature of the external envi largely unknown It seems however undis ronment, like those of the internal environ puted that the degree of peripheral vasocon ment produce vasomotor responses predom strictıon beass a relationship to systemc ar inantly in the surface Vessels Exposure to a terial pressure whether this is a function of cold environment causes construction of the general peripheral resistance of one or more surface vessels diminishing heat loss and specific vascular beds is under dispute conserving body heat Exposure to a warm The effect of cold induced vasoconstriction environment is followed by dilation of these on systemic blood pressure in man has been Vessels and heat loss observed and u ed to determine asomotor a Reflex Vasodilatation (Cibbon Landis reactivity Baseline blood pressure readings Procedure) Vasodilator responses in the ex are recorded then the ubject s other hand is tremities may be ob erved and evaluated by ex immersed beyond the wrist in water of 4 C posing the body or reasonably large parts of it for one minute while the blood pressure is re to heat or warmth 175 177 This or any erper corded every 30 seconds After removal the iment designed to test vasodilatation should hand from the water blood pressure is te be done against the background of mild vaso corded at 2 minute intervals The maximum constriction There are a number of pro rise of sy tolic and diastolic pressures is noted cedures described in the literature but we as also the length of time before basal readings have found the standardized method of Gib are reached and the length of time it takes bon and Landı$178 most convenient and te for the pressure to return to basal levels after liable We use this procedure The patient immersion An increase of 20/15 mm Hg in a basal state lyın, comfortably on a bed blood pressure a pre experimental period of 15 made to adapt to his environment in the 20 minutes and a post immersion period of 2 constant temperature room maintained at 20 minutes are con dered normal Values ex C(+05 C and 55% humidity The patient ceeding these figures are interpreted as an in is considered adapted when the surface dication that the subject is a hyper reactor temperature at the plantar surface (glomus and that he has a hypersensitive vasomotor area) of the big tot has remained constant system The procedure is used more as a for at least 30 minutes as recorded quası screening test to find potential hypertensnes continuou hy a Speedomax recorder An than to judge sa omolor reactivity in patients arm of the patient is then immer ed up to with peripheral vascular disease beyond the bend of the elbow in a water bath d Cold Test This is a simple test where maintained at 43 44 C for a period of about the patient immer es hi hand in Water 45 minutes Vasomotor responses in the ex maintained at 15 C temperature if the test tremities are evaluated by periodic determina is positie a urticarial or an angioneurotic trons of rate of blood flow measured with a edema like reaction occurs in the immer ed large part venous occlusion plethysmograph part There may al o be systemic manifesta b Reflex I asoconstriction 179 The op tions which surge t a hı tamın like reaction posite reaction is achieved of a part of the Capıllary micro copy reveals blurring or hazı body is cooled in tead of warmed This ness of the outlines of the capillary loops due should be done again t a background of mild to the production of edema probably re ult vasodilatation for this purpo e as in any ing from increa ed permeability of the capil type of experiment to test va oconstriction the lary wall This procedure is a test for vascular constant temperature room is kept at 25 26 C hypersensitiity to cold rather than for vaso with the humidity at 55% motor reactivity per e c Cold Pressor Test 180 The various fac 3 Responsiveness to Pharmacologic tors that influence blood pressure are still Vasomotor igenls Various drugs have ·30 PERII ERAL CIRCULATION IN IIEALTH AND DISEASE Used 170 17 and 10dinated scrum albumen laie ben 1 Responsiueness to Changes in Tem Both are excellent measures of perature of the Internal Enuronment blood volume in the part examined The in Following profuse hemorrhage or other states terpretation of peripheral pick up with a characterized by loss of body heat a train of Ceiger counter or a scintillation tube in terms physiologic events sets in seemingly devised of blood flow however is rendered rather to con erre heat and to prevent further loss difficult by the diffusion factors and the surface vasocon triction takes place The con physiologic shunting devices sequent cold cen ation has provided the term chull for the symptom complex represent TESTING OF VASONOTOR RESPO\SES ing the attempt to restore body temperature Under normal conditions Tasomotor re the heat loss has been great On the other sponses are clicted when the individual is ex hand in febrile states where there is excessise posed to vasomotnje forces The nature or di production of body heat vasodilation of the rection of the response is specific for any one surface vessels takes place increasing heat stimulus although the magnitude may vary loss by radiation and convection Thus nor within certain limits in different indivduals mally actre sasomotion occurs at least in the and within narrower limits in the same indi surface ses els in re ponse to changes in tem vidual However this directional specificity perature of the internal environment Lo s of may be said to exist only in certain vascular responsii ene s indicates d ea e of the ses els beds for other vascular beds in the body may or di turbance in the regulatory mechansm not only not re pond but may even exhibit the Injection of typhoid vaccine which was opposite reaction to the same stimulus at the used in the treatment of thromboanguinis ob same time such type of response in turn be literans has been employed by the same work ing specific for these other beds Thus if vas ers173 174 to evaluate the va omotor respon es omotive stimuli physiologie as well as phar in the extremity The intravenous administra macologic, are classified as vasodilator or tion of 50 to 100 million dead or attenuated vasoconstrictor it is most desirable that their bacall us followed by a sequence of events action be specified in respect to the vascular comprising (a) a latent period of about two bed or beds concerned Various physiologic hours and (b) a evere chill with rapid rise states and many pharmacologic agents are re in body temperature reaching its maximum ferred to as peripheral vasodilators or pe within 1 hours and subsiding gradually to ripheral vasoconstrictors because their occur normal The rice in skın temperature and in rence or admını tration is followed by the crease in mouth temperature are noted as respective vasomotor response in the blood well as the difference between those two values Vessels of the extremities However until bet (attributed to peripheral vasodilatation) ter methods can be desised so that the blood The e are u ed in a formula the Va omotor low in the vascular beds of the skin and mus Index (Brown) presumed to be an expres cles can be separated more accurately the ad sion of the capability of the small peripheral dilse effect of their responses have to be Te sels to dilate The index is obtained from taken as the vasomotor re ponse of the er the ratio of the difference between the two tremity as a whole On the basis of these increases of temperature over the increase in blood (mouth) temperature a vasomotor in facts certain physiologic states have been ar der of 15 or more is taken to be indicative tificially induced and sarious pharmacologic agents have been administered to evaluate the of good vasomotor responsn enes The plea ant side effects and the dangers of the vascular tatus of the extremity under the as procedure have prevented its widespread use cumption that the va cular integrity is directly correlate to the normalcy (in degree and in 2 Responsneness to Changes in Tem direction) of the va omotor response elicited perature of the External Fnrironment ·33 FLALLATIO OF BLOOD FLOSS there ma) jou be applied to differentiate between lin and be the eparate circulation, in mu cle for through multaneou mea ure mu cle one controlled bs the 12.omotor con ment 119 Similar limitation and difficulties in ire and the other bis metaboliten Eve hit 2 interpretation app's as in thermometry The at mas it in obviou that the re-ponse of var procedure is perhaps better applicable to mu 18 rular bed to a omotor drum mult cle flow than to kin flox ince it mea utes vary according to the regulators meclian m origen con umption and there doe pot a actise at the particular bed sery definite relation bup bulbeen work per 3 Relaison hips among larsoll la formance and mu cle flow cular Bells The fact that a omator rec Plethy mographs of large parts per pones vary from bed to bed cau e tran mis eparate e-timation of mu cle flow and po iton of blood from one asea to the other kin flow by u ing forparm or leg for estima Thi bifting of blood volume within the cir tion of mu cle flow and hand or foot for es culators , terti obrou ly a rather impor timation of kin flow tant factor in hemodenames Unfortunately The va cular bed of the kin as predomi informations still very incomplete and many nently concerned with heat regulation and a theory adsanced over the sears! till aw sit therefore readsly repond to change in both ing conclu ile experimental and clinical con the external and internal enssronment These firmation Probably the ben! was or gathering se pones may be elicited durectly a well as information on the problema compler x the by Central Teflex and are almot entirely one employed by Skarpe, Shafer and bar codependent upon the 3 omotor Interna worker 15* They have tudied the effect of uch rapid method of changing esteulafzon a The va cular bed of the beletal mu dles 36 alsering the porture heating cooling exerci e ha been hown by Grant?" and ht to workers and titse Val als a maneuver As far a- the two that in contra to the kin led a cular se mBir a cular beda in extremines are con pon in the keletal mu cles were chiefly cerned it appears mont likely that huling of dependent upon the action of metabolites pro blood from the con lo mi cle and recerca duced during acturity Batcroft and his ca does occur Thi seems to be mot plau ible workers have a certained that the ta oma *hen ne con der the differences in apportion for centre can regulatt, the ba al Row in my ing of blood to the kin and mu cle repec le but unable to influence the circulatory tusely in re pon e to cooling warming and er changes during activity This fact 23 vnet erci e a well a the sa ospotor phenomena plained as is the phenomenon of the impa routected with interruption of nenou regu thetic denersation of a limb increa ing ba al latory mechanı m911 The occurrence of flow but depriving the limb of it capability hilting of blood between 12 reral and ren to recess reflex incrra e in blood flow through pheral bed in man, far from proven to bods warming These unexplained phenom ome workers it appear to be an almost ut ena are mot likels related Barcroft and lux 21 oidable po-tulate for explanation of certain as ociates esen ponder the pos sulity that lealuses of hock and hyperten ion tion 131 130 ·32 PERITIERAL CIRCULATIOY IV HEALTH AND DISEASE been used in the treatment of peripheral vas vascular beds in the extremity, namely, in the cular disease becau e of their supposed taso bones the skeletal muscle and the kin The dilator or kasospa molytic properties. They vascular supply to the connective tissue found are discussed in detail in Part IV With pach between the individual muscle bellies and sep drug physiologic experiments conducted un arating shun from muscle in certain place der well controlled conditions should be per scems of minor if any significance Va cular formed to demonstrate the alleged pharmaco supply to soft it ue structures in and around logic properties when investigating asomotor the joints is of great interest but there is no respon as it is of paramount importance that method asailable to measure blood flow to the controlled conditions include ba al condi these structures in man Blood flow to the fions of the patient as well as the facilities bones may be measured 185 however the of a regulatable con tant temperature and hu mtthod is tumbersome and has not proven midity laboratory rewarding so far VASOMOTOR RESPONSES IN THE There are three main reasons for separating skın ſlow from muscle flow (1) The impact EXTREMITIES of vascular disea e may be equal on the two I Relationship to the Heart The heart beds but more often is found to be predomi serves as the rentral pump that throws into the nantly on one of them at the time (2) The Bascular system a given amount of blood at regulatory mechanisms chielly responsible dif glich intervals at a guen pre sure and with fer in the two beds skin flow is to the grcale I a gren velocity it is obvious that changes in part regulated by sympathetic innervation the pumping mechanism must be reflected while rate of muscle flow mostly depends on in the peripheral circulation and that such the circulation and transport of metabolites in respon e becomes measurable wliencier it work performance (3) The respective re reaches a magmtude sufficient to be docu sponses of the two bed to the same stimulus mented by the limited methods available at may difier quantitatnıely or even direction pre ent Clinically the re pone in the ex ally tremity beds to decrea e in cardiac output may There are at pre ent three methods available be found to manifest itself directly in two that permit an approximate separate estima Way in arterial construction and in pool tron of muscle low and skin Now in human ex ing of blood in the minute ve els When car tremities drac output remains markedly diminished for & Thermometry a prolonged period of time as in certain rases u ing <imultancou ly of light mutral stenosis the ensuing picture in thermocouples inserted into muscle belhes and the extremities might be almost indistinguish thermocouples affixed to the surface of the able from that of peripheral arterial insuffi limb Registration of surface temperature is an indication of blood flow through the kın ciency due to intrinsic occlusne peripheral ar terial disease This includes even such ex anly under certain circum tance 166 IR Lo treme manifestations as marked trophic cal effects of insertion of the thermocouple and the fact that merely local temperature is mais changes and gangrene both of which may oc ured in a few places rendre conclusions con cur without the pre ence of a ball vahe turum certing blood flow to the whole muscular bed of the part difficult 18% l'asically thermometry Conversely marked changes in the distribu (ems better apphcable to the kin bed than to tion of blood olume within the peripheral the muscle bed since heat regulation is the Vascular system mut neces arily affect the out tanding phy 1ologic function of kin mechanics of the heart 183 184 2 lite Vascular Beds within the fx tremily There are at least three distinct b The ve of the oxygen electrode may bus 181 182 flowy 189 ·35 BASIC ASPECTS OF BLOOD FLOWY Oth Int ratio al Congres of 1 hysiology Brussels Belgium Augu tl 1956 31 EDITOLM OG Fox RH AND MACPHERSOY RA The effect of body heating on the fore arm bloodflow Presented at the 20th Inter national Congress of Physiology Brussels Belgium August 1 1936 3) Roddie IC SHEPHERD IT AND WHELAY RF Vasoconconstrictor and vasodilator nerves to the human forearm Presented at the 20th International Congress of Phy iology Brus.els Belgium Au,ust 1 1956 33 F ODDIE I C. SHEPHERD J T AND WHELAN RF The independence of the nervous con trol of the kin and the muscle ves els in the human forearm Presented at the 20th Inter national Congress of Phy jology Brussels, Bel gium Augu t 1 1956 31 BEARY AC BILLINC GHI EptJoLM OG SHERLOCK S Effect of adrenalin and nova drenaline on hepatic blood flow and splanch nic carbohydrate metabol se in man J Phys 101 115 412 1991 35 BRADLEY SE Variations in hepatic blood Row in man during health and disea e New England J Med 240 691 1919 36 WRICHT IS AND LUCKEY E H Cerebral Vas cular D cases New York Grune & Stratton 1955 37 KETY S S Physiology of the cerebral circu lation in cerebral vascular di ease In Ciba Symposium New York Grune & Stratton 1955 extracts from blood vessels Acta physiol Scandina: 56 1 1918 43 FRIEDMAN MM Studies concerning the eti ology and pathogenesis of neurocirculatory a thenia III Cardiova cular manife tation Am Heart J 30 4,8 1915 41 LEWIS T The Blood le el of the Human Skin and Their Reyon es London Shaw 1997 45 LUNKEL, T STEAD EA AND WEISS S Blood fow and va omotor reaction in the hand forearm foot and call in response to rhysio logical and chemical stimull J Clin Invet 18 223 1939 46 BRICDEN W HOWARTIES AND SHAAPEY SCHA FER, EP Po tural changes in pepheral blood flow of normal ubjects with ob er a uons on acosagal fainting reactions as re re ult of tulung lordotic po ture pregnancy and pinal anesthesia Clin Sc 9 79 1950 47 BRICDEN W AND SHARPEY SCHLAFER EP Postural changes in peripheral blood flow in cases with left heart failure Clin Sc 9 93 19 0 3 SHORRE Role of hepatorenal va pactise fac tors in etperimental stock and in experimen tal renal and human es ential hypertension (Alvarenga prize lectu e) Tr & Stud Coll Physicians 19 14 1951 39 SHORR E ZWEIFACI BY FURCHCOTT RF AND BLEZ S Hepatorenal factors in curcu latory homeo tas tiesue origin of vasotropic principles Eli and VDIT which appear dur ing evolution of hemorrhaic and tourniqu! shock Circulation 3 49 1951 40 BIEDI, A Innere Secret on Berlin Urban & Schwarzenberg 1913 11 COLLWITZER VETER h. KRAMER AND KRUEGER E Die Wirkung des Adrenalins auf die Energetik des Herzens Arch fdgs Physiol 237 639 1936 12 SCIMETERLYEK CG The nature and occur rence of pressor and depressor sub tances in 48 ABRAMSOY IS AND FERRIS | B Respon of blood vessel in re ting hand and forearm to various stimuli Am. fleart J 19 511 1940 49 GRAYSOY J Observations on blood flow in hu man intestine Brit MJ 2 146, 1950 50 MATHES Regulation of skin blood flow in Coba Sympo rum Bo ton Little Brown 1953 p 180 51 VCDOWALL RJ S Reactive hyperemia In Ciba Sympo sum Bo ton Little Brown 1953 p 173 5? 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AND COOPER AE Vaso ·31 PFRITIFRIL CIRCULATION IN JIEALTH AND DISEASE References-Part I 1 SOBOTTA J In McMurrich Ed Atlas al llu man Anatomy New York CE Stechert 1936 2 COWDRY EV A Textbook of Histology Phila delphia Lea & Febiger 1938 3 BREMER J L A Textbook of Histology Phila delphia Blakı ton 1936 + VAXIYON AA AND BIOqy A Textbook of Ili tology Philadelphia Saunders 1938 5 Roucer C Note sur la tructure de l oeil et en particulier sur l appareil in choriordiac Part Refr pre we med de Paris 1856 6 SHELY GA Om bet Norrkomen van de cellen van Rouget op den wand van de capillairen in het oog van den mench Croningen b Den Haap JB Wolters 1976 7 PARMER 6 II Are there Rouget cell on the blood vessels of intervertebrates Anat Rec 26 4 1923 8 BAUNO LOBO F A celula de Rouget Rio de Janiero Compannie Brasileire de Artes Cra fices 1915 9 Risca B The contribution of electron micros copy to the physiology and pathology of cir culation Pre ented at the 20th International I hysiological Congre Brusels Augu) 1956 10 TONTILLER P AND VANOTTI 1 Die Camil larmicroskope mit starken Vergroes erungen Berlin & Vienna Urban & Schwarzenberg 1929 tor hibers in human skin J Clin Invest 96 453 1917 17 FCCLES IC Conduction and synaptic trans mision in the nervous system Ann Rev Physiol 10 93 1948 18 DALE I Reszuelvertragungen durch chem i che Mittel im ganzen Nervensy temn Wien hlin chaschr 65 155 1953 19 BURY J II Mechant m of action of chemical sul tances at nerle endings and part played by peripheral ganglia Acta physiol Seandı has 29 10 1933 20 BAYLISS TM The Va omotor System Lon don Longmans 1923 91 FRANKLIN AF A Vonograph on Teins Ball timore Thomas 1937 22 FRANALIN AF Aspects of circulation econ omy Brit MJ I 1311 & 1410 1951 23 KROGE 1 The Anatomy and Phycology of the Capillaries New Haven Yale Univ Press 1929 94 LANDIS EM Recent studies on capillary per meability Tr Ar Clin & Climatol A 60 161 1919 -5 KETY SS AND SCHMIDT CF Ffects of sc tive and pa sive hyperventilation on cerebral I lood flow cerebral orygen con umption car dsac output and blood pres ure of normal young men J Clin Invest 25 107 1916 P6 CRAYSON J Role of the inte trnal circulation in the va cular economy of the lody In Vis ceral Circulation Boston Little Brown 1993 Va omo P 230 11 CHAMPERS RAND ZWEIFACH BW tion in hemodynamics of blool capillary circu lation Ann Net York Acad Sc 40 519 1918 12 CHAMBERS HAND ZWEIFACH BW Intercel lular cement and capillary permeability Physiol Rev 27 436 191 13 BEST CHAD TAYLOR NB The Phy510 logical Basis oi Mednal Practice Balumore Williams & Wilkins 1950 14 VUELLER O Die Kapullaren der menschlichen koerperol erfaeche in gesunden und kranken Tagen Stuttgart Enke 1999 15 LANGLEY YA The Autonomic Neslous Syg tem Lambridge Heffer 1971 16 SARNOFF S J AND SIMEONE FA Va odila PADI CU W WERTHEIMER L DELISLE C AND STEIE J 11 Comparison of s ceral and peripheral va cular beds in hypertensne pa tient their re pon es to various hypoten e drugs (i culatton 9 68 1951 3 LEN TAND PICKERING Va od latton in the limis in re pon e to warming the lody with cudence for sympathetic va odulator neries in man Heart 16 33 1931 9 BARCROFT JI Problems of sympatheti inner ation and deneration Brut Bull 8 363 1952 30 EDHOLM OC FOY RHAND VACPERSOY R The va amotor control of the cutane our circulation of forearm Ire ented at the ·37 BLSIC ASPECTS OF BLOOD FLOIT 90 KRAMER D Vanual of l'eripheral la cular Durder Philadelphia Blakı ton 1910 91 BAYL The asomotor Si tem. 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LENIS T410 MANER I V laylar reac tions of kin to injury further evden e of relea e of furtam neke ul tan c from in jured kin fleat 14 19 19 88 LENT la cular reactions of the kin to in Jur) Heart 11 119 1921 89 STARR I The value of th cutaneous I, tamine reaction in the prognor of selal le tone 1 diabetes mellitus Am J 11 Sc 188 4 1931 ·39 BASIC ASPECTS OF BLOOD FLOWY phenomena in health and do ea e Surg Gynec & Obst 55 731 1937 153 JOHNSOY CASCUPHAM GW AND GILBERT N C Studies on peripheral vascular phe nomena Surg Gyner & Obst 5) 637 1937 154 SCUPAAN GW AND JOHNSOY C4 Peri pheral vascular phenomena Arch Int Med 59 877 1933 155 BURCH GEA new gen tre portable plethy mograph Am Heart J 33 48 1917 156 JOHNSOY CA The measurement of the pul satile arterial circulation Surg Gynec & Obst 93 735 1931 137 ABRAMSO DI Va cular Pespon es in the Ex tremities of Man in Health and Diseasp Chi cago Univ of Chicago Press 1911 158 ABRAMSON D I ZAZELLA HAND VARRUS J Plethy mographic studies of peripheral blood flow in than Am Heart J 17 194 1939 159 GRUNDFEST H HAY J J AND FEITELBERG S A strain gauge recorder for physiolo ical vol ume pres ure and deformation mea urements Science 101 255 1915 160 WIDE C Fluid D placement and Plethysmo graph in Methods in Medical Pe earch Vol I p 182 Chicago Year Book Publishers 1918 168 COMROE V H JR AND WALKER P Normal human arterial oxygen saturation determined by equilibration with 100% orygen in vivo and by otimeter Am J Physiol 152 365 1910 169 VOYTCOVERY HAND HOROWITZ 0 Oxygen ten ion of ti nes by polarographic method introduction orygen tension and blood flow of skin of human extremities J Clin Inve! 29 11'0 1950 10 Smrt. 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C Range and variability of blood how in human fingers and vasomotor regula tion of body temperature Am J Phys ol 127 437 1939 165 SINVONS HT Intermittent claudication and its quant tative measurement Lancet 1 73 1936 166 HITZROT LH NAIDE M 410 LAUDIS E MI Inte mittent claudication stud ed by a graphic method Am Heart J 11 513 1936 161 KEYS A The oxygen aturation of the venous blood 10 normal human subjects Am J Phys. rol 124 13 1938 ·38 I ERITIERAL CIRCULATIOV IN HEALTH AND DISEASE Blood pre sllaries by a new technic Ann Int Med 121 137 AMDURSXY SS The sphygmotonograph its 1938 function description and operation her 192 GOLDBERG SG Calcium gluconate as a circu Scient Instrumento / 517 1930 lation time te Am J A Sc 192 36 1936 138 PEARSE II E. AND MORTOY ) ) 123 BLUVCART IL The velocity in I lood flow in sure in arteries of extremities in normal sub health and di case Medicine 10 1 1931 jects and in peripheral vascular de ea. Am J Med Sc 183 485 1932 114 Roeb GI AND WEISS S Nethod for measur ing of velocity of pulmonary and peripheral 139 ALTEN E BARKER NW AND Ives E A venous llod flow in man Am Heart J JR Peripheral Vascular Diseases Philadel 8 650 1933 pha Saunders 1955 123 Rune C P AND WE S The velocity of pul 140 STEWART CN Studies on the circulation in monary and peripheral venous blood flow and man Heart 3 33 1011 related a pects of the circulation in car lio- 141 KECERREIS R Calorimetrar tudies of the ex ta cular disease Am Heart I 742 1931 tremities and experimental apparatus and 196 IIALDANE J S AND SMITH JL The ma s and procedure J Clin Insest 3 357 1926 oxygen capacity of the blood in man J Phy stol 25 331 1900 142 BROWN GE Calorimetric tudies of the er tremties ) Clin Invest 3 364 196 127 XEITH NM RowNTREE L G AND GERACHITY JT Method for the determination of plasma 143 TAYLOR NB Blood How in man as climated and blood volume Arch Int Ved 16 517 by the calorimetric method of Stewart ) 1915 Lab & Chin Ved 7 430 1922 128 CPOONE A CAND MORRIS C. JO Determ 141 SHEARD C Calorimetric studtes of the extremi ination of plasma yolome by Evang blire Lies (Stewart s method) J C) Invest 3 397 method J Physiol 101 217 1912 1926 139 ERLANGEX 1 Blood alume and its regulation 145 MENDLOWITZ M OD ersation on the calor I kysiol Rev I 177 1921 metric method for measuring digital blood flow An.tol 1917 1950 130 ROW YTREE LC AND BROW GE The sol ume of the blood and plasms in health an 146 MORTON J J AND SCOTT IM The reas disease I hila Jelphia Satinder 1929 urement of sympathetic va oron triction ac tivity in the lower extremities J Clin Invet 131 FRLANCER J A new instrument for determin 9 23, 1930 ung the minimum and maximum blood pres Portable sure in man J Hopkins llop Reports 12 53 147 BAZETT HC 410 McLLOVE B 1001 thermoelectric apparatus for the determing tion of surface and ti ue temperatures 132 Pactor 3 Sur la methode des o callations Lab & Clin ved 1° 913 1917 et des conditions correctes de on emploi en sphygmomanometrie cmique Compt rend 118 SHEARD C The electromotose thermometer an Soc de biol 66 733 1909 Intrument and a method for measuring in tramural infravenous superficial and cavity 133 PACION Y Sphygmometrit oscillometer eưu temperatures Am ] lin Path 1 209 1931 cation physiqu et criteres fonctionelles les variations de la pre ston arterielle (rifere 119 SAVUELS SS A new skin thermometer New dentrairement Compt ren i Sor de biol 21 York State J Med 40 884 1910 1910 150 REDISCH # SRECANAN E Ara STEELE JA 134 LAQUEZ H GLEYI AND COUTEZ D Une Skin temperature se pone of normal human nouvelle etape de la sphygmomanometrie La subyer is to various conditions Circulation determination des pre sions minima et moy 6 86' 193. enne par la methode oscillometrique Presse 151 RenSCH W TANGCO F PCRTIET IER L med 39 981 1931 LEWIS A AND STEELE JM Ya omotor re 13Bara DR A new recordin, phygmomano spon es in the ertremities of subjects with meter JAM 1 89 1513 1927 Sarious neurologie lesions 1 Reflex responses 136 SASIUELS SS The alue of oscillometry in to warming Accepted for pu) lıcation in Cor ulation the study of the circulatory disturbances of the extremities JAMA 88 1.80 1927 15. JOJI YOY CA Studies in peripheral vascular ·Part II Pathologic Alterations in Peripheral Blood Flow CHAP 1 CUTE INTRINSIC VASCL LAR DISOR DERS Arterial Segment Venous Segment Vinute Vessels CHAP 2 CUROVIC INTRINSIC VASCULAR Dis ORDERS Arterial Segment Venous Segment Minute Ve els Disease and Injury of the mous System Disturbances in the Endocrine Sys ten Thyroid Adrenal Medulla and Chromaffine Sy tem Adrenal Cor ter Gonads Pancrea Pituitary Changes in General Circulation Ibnormalit es of the Musculo Skel etal System Changes in the Composition of the Biood Sen itivity Reactions CIIAP 3 ALTI RATIONS IN BLOOD FLOW DUE TO EXTRINSIC CALSFS Traumatie Injuries CAUSE and pain AUSES FOR ALTER 4TION II Peripheral Tissue necrosis (u ually called gangrene when blood flow are of course manifold Most the extremities are concerned) ensues when changes repre ent physiologic responses to ever the arterial blood upply to the part is various needs arising within the body s econ markedly impaired or totally obtructed omy in the fulfillment of lifes daily require When the venous part of the circulation is ments affected drainage of blood from thr part is im Changes in peripheral blood flow due to paired This leads to stagnation of blood and pathologic interference may be conueniently accumulation of wa te products including disded into two main groups alterations CO causing in turn discoloration changes caused by and representing sequelae of intrin in surface temperature swelling pitting edema sic disease of the blood vessels and alterations representating re pone to and equelae of Finally interference with proper function pathologie proce es outside the vascular sys of the minute circulation affects metabolic ex tem change through the <apıllary wall and may Pathologic processes affecting blood flow lead to increased capıllary permeability local may manile ! them eles predominantly in edema diminution or loss of capillary respon one or more of the three main segments of the to timuli (usually referred to as lo s of ca vascular tree producing the equelae of inter pillary tonus ) hemorrhage and even ne ference with the inherent function of the af fected segment Thus pathologic proce es Alte rations in blood flow may be acute or affecting the arterial egment cause dimini hed chronic rever ible or itreversible Obviou ly or inhibited suprly of arterial blood to the where uch alterations result from extravascu part leading to privation in nutrients and ory far pathologic proces es all parts of the vascu gen this in turn cau es pain pallor change lar tree may be affected at the ame time in urface temperature and trophic changes Moreover even in the ca e of intrinsic vascu 41 crosis ·40 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE 181 EVANS ME Ball thrombus of heart Brut Heart J 10 31 1918 182 FVAN W AND BENSON R Va s thrombus of Jeft auricle Brit Ileart J 10 39 19 18 183 HOLYAN E Arteriovenous aneurysm Abnor mal Communications Between the Arterial and Venous Circulations New York Macmi! lan 1937 181 FRIFDDERC CN Di eases of the Heart Phila delphia Saunders 1950 187 REDISCIE #SMECKNAN FAND STEELE JM Skin temperature re ron e of normal human ubjects to Sarious conditions Circulation 6 862 1952 188 FRIEDLANDER M SILBUT S BIERVAN AND I ASKEY N Differences in temperature of kin and mu cles of the lower extremities fol lowing various procedure Proc Soc Exper Biol & Med 33 150 1938 1P9 SHEARD C Temperature of skin and thermal regulation of the body In Clas er 0 Vedi cal Physics / 1523 155) 1911 190 RICHARDS RL The Peripheral Circulation in Health and D. ea e Ralumore Tallrams & Wilkins 1916 191 GRAYT RT Ob ervation on I lood circulation in voluntary muscle in man Clin Sc 3 157 1932 18) Ducury MARQI EY P Baux R. L'AILLE J AND VOISON (TOULOUSE) R Physiologie de la circulation 04 ene J de radiol et d electrol 32 189 1951 186 ALLEN E BARLER N AND HAVE EA JR Peripheral Va cular Di cases Philadel phía Saunders 1952 ·43 ACUTE VASCULAR DISORDERS a thrombus forms locally on the basis of the cavity the outer part of the seasel wall eems atheromatous ulcer in the vessel wall and at a to have & marhed re istance to bacterial inca certain moment occludes the vesel lumen ion which account for the relatively rare in Very frequentli atheromato is occurs in com cidence of uch event when it occurs it bination with obliterative arteriosclerosi tarts as a periarteriti with polymorphonu dreame to be di cu ed later Likewise athero clear leukocytic infiltration of the entire ve cel eclero-ts is frequently superimposed upon ob wall and destruction of the ela tic lamına Iteratase thromboanguitis (usually called which in turn may result in esere or fatal Buergers Di ease ) Acute thrombotic ar hemorrhage terial occlusion may al o occur following an Scule endarteritis following lodgment of a acute inflammatory process in the arterial wall eptic embolus from a eptic thrombus or from Primary acute arteritis is a rare condition the vegetation of an acute or subacute endo but does occur e pecially in children Two of carditis may alo lead to acute arterit with the ca es reported by Kramers were ob ered inflammation and infiltration of the whole ar in boys and a third in an elderly woman In terial all the reultant secondary thinning these ca es the condition appeared as a gener cau es the formation of a mycotic aneurysm alized arteritis All the arteries both large and or rupture of these sel mall were involved although the medium size and maller arteties showed the greater generalized injections and inflammalory proc Acute arteritis ma abo occur secondary to changes Pathologicalls there were swelling esses Disea es that have been mentioned as and proliferative changes in the intima with necrosis in some area In other areas thrombi inuolung artenes with ab equent development of were found on the intima with complete oblit gangrene include typhus feser *s influenza eration of the lumen in some le sel The me diphtheria streptococcic ore throat, ery dia was frequently involved with infiltration of pela« 39 anthrat gonococcal infections 39 ma laria " and rheumatic fever +1-41 The symp all types of cell followed by hy alıne degen eration and fibrosi There was al o cellular tomatology is neces anlı dominated by the infiltration in the adventitia and in the peri primary di ease the va cular involvement pre Vascular ti sues The symptomatolog is es en sents a complıcation either in the acute clini tially that of an acute infectious process with cal tage or during con ale cence Sympto a clinical picture of a severe toremic state with matology referable to the arterial complication 2 udden onset remittent feser rapid pule depend upon the le of involiement and var headache mulai e vomiting generalızed les in eterity according to the completeness of vascular occlu son rangng from ungling pains and pains in the extremities of varying intensity Purpuric hemorrhages may be seen and numbness to actual pain with blanching coldne on the body or more prominently in the ex discoloration and gangrene of the tremities especially in the lower limbs There part. may be gangrenous areas of varying izes de Subacute non pyogenic arteritus has been re pending on the caliber of the arteries in olied ported as a complication of typhoid fever and When the larger trunks are involved the im epticemia (bacterial emboli) 45 pneumonia pairment of the penpheral circulation is quite and scarlet fever (due to fovic capillary in evident, with lo s of the pul e coldnes of the jury) and other general infection The lower extremity discoloration and ultimate exten extremity ses els are mostly involved ise gangrene There is leukocytosis with pols Rheumatic arfertis is a well de cribed mor nucleosis platelet count bleeding and clothing phologic entity in olving the mall arteries the time remain normal arterioles and the capillarie and has been Secondary acute arterius may occur for in reported to insolve a variety of such periph stance when the vessel traverses an absce s eral ve els as the cerebral pulmonary cor ·42 PENITIIERUL CIRCULATION IV HEALTH AND DISEASE lar diseases, in many instances should the dis turbance last for a prolonged period of time, all segments ultimately participate to some degree Various types of pathologic processes affecting peripheral blood flow hase of course, various organs as sites of predilection Dis cussion pre ented here will predominantly con der blood flow to the extremities Chapter 1 Acute Intrinsic Vascular Disorders tis 1 2 ARTERIAL SEGMENT eases leading to cachexia mulnutrition are Acute arterial occlusion is the term used factors to be considered in the development of for those incidents in which the main arterial micotic thrombi in peripheral arteries how supply to the part appears to be cut off rather ever thus ss estremely rare except in the pres suddenly Symptomatology may he instanta ence of acute or cubacute bacterial endocardı neous but more often develops within minutes to an hour in the extremities the presenting etiologie factor responsible for acute throm Atherosclerosis is by far the most frequent symptoms are coldness (subjective and objec tive) pallor and numbness The pallor soon botic occlusion of peripheral arteries 3 A ghe way to a mottled cadaverous appear • Atherosclerosis or atheromato as it used to be ance and the numbness to intense pain, the called is characterized by a fatty change and fibrous affected part of the limb becomes extremely thickening of the intima of the larger arterial ses els With the more effective control of infectious dis sensitive even to light touch eave and the re ultant lengthening of the popula Acute occlusion in the arterial tree may be trons life span there is an apparent increase in the caused by an embolus or by local thrombus incidence of degenerative disea es™ Thus athero formation Differentiation is often difficult but clerosis and arteriosclerosny which had heretofore hould always be attempted because of essen been looked upon as barely more than stigmata of aging are being con dered more and more for their ual differences in management The present pathogenic potentiales Becau e of their relaire ing symptomatology is identical Suddenness irresersibility once established they represent per of onset is not of great help since in many haps the most potent threat to that lengthened life case only the complete thrombotic occlusion Consequently atherosclero a$ and arteriosclerosis with its dramatic equelae makes the patient have become the subject of intensive investigation while much information has been gathered, their and his surroundings aware of the pathology pathogenesis is far from understood This book is while the preceding slow development of such hardly the place to review these studies Two discrep pathology may be entirely overlooked or ant hypotheses regarding ettology might be mentioned misinterpreted There is a striking smilanity The most widely accepted "diet hypothesis 3 31 pro of events to those encountered in many cases poses that due to a disorder of fat in tabulist an ex cese of lupad material occurs in the blood stream of myocardial infarction due to thrombotic whi h in turn leads to fatty deposits in the arterial coronary artery occlusion nal] The presence of such lipid deposits induces re The best lead to a deci jon whether acute actise oler growth of connective tigsue resulting in occlusion of an extremity artery is thrombotic fibrous thickening of the arterial intims On the other hand proponents of the "thrombus" hypothesis think or embolic in nature is the evaluation of the that sclerotic lesions are altered thromb! mural patent as an individual ca e The presence of chrombosis is believed 10 he possibly the consequence heart disease especially of rheumatic etiology of some abnormality in the various factors related to in the absence of peripheral manife tations blood coagulation 3 34 According to this concept a mural thrombus that has formed in the vessel wall of vascular di ease speaks strongly for em becomes overed with endothelium and thus becomes bolic and against thrombotic occlusion and incorporate i into the ne el mall and with subsequent vice versa Meticulous search into the history organization fatty changes ocrur which mht lead 10 is of great importance Blood dyscrasias dis softening ulceration and even calcification ·45 ACUTE ASCULAR DISORDERS e tabli hed Attempts to differentiate phlebo pack of enlarged lymph gland. 96-99 3 Pro thrombo is from thrombophlebiti 63 at leat longed bed rest e pecially in obese and elderls clinically are unrewarding of not impo ble indundval as frequently a ociated with ve- The mechan mo of intrava cular coagulation is nous thrombo s 10 10. not clearly understood For a di russion of the Superficial thrombophlebins involving the ubject and review of the literature, the work of Helch" and Aygaard's hould be referred caphe nae s tem producing a v ible and pal pable painful cord oflers no diagnostic prob to Various factors are known to influence or lem and as a a rule of little gnificance flow to play a part in it production but the extent of their re pertive roles is unknown Among ejer at may be of diagnostic import in the hi fory of obliterature thromboangntre them art injury to the veanel wall, 6! 6 ob truc tion or slouing of the blond stream" change Deep enous thrombosis is a bother one in visco ity and comro ition of the blood (i often painful condition with a tendency to se albumin content) and changes in the coagu currence and to establi hment of chronic * Haine properties of the blood & quelae Its mot erious a pert honerer the Damage to the venous all may be due to occurrence of embolim An estimated 80 to intrinsic d ene (pecially phlebo clero is) or 90% of thrombo es perur in the lower er It may te of infectious (e. poeumona influ tremities most of them in the calf veins 103 The enza isphoid fever) traumane (eg, fnllouing diagnosis of deep venous thrombo is 1 ba ed antravenous instrumentation) mechanical on the described circum tantial evidence and chemical peruvenous infiltration) of tumor the igns and symptoms due to impaired ve metastatic origin 989 It may al o be produced nous drainage deep mu cle tenderne painful by direct exten ion from local uppurative foci hot red and indurated overlying km Apoi as in puerperal ep 1 mastoiditis and osteomy ense Homans ign pain on dorsiflexion of the elutis foutl 1s helpful in tabli hing the diagno is Changes in 9a, ulatuse properties of the while a negatre tent does not exclude it by any Blood occur under various CIICUB lances for means As is to be expected ma t embolic epi largely unknown rea ons and their role in odes ani ing from thrombı itt sy temnic veins thrombu formation is not 100 well establi hed occur in the lungs Paradorical emboli mto Arceleration in the prothrombin activation the brain or to the extremities may occur in the mechanım has been found to occur in pot pre-ence of a patent foramen ovale 1 patient operalle and po tpartum tales "9 and this who enher has manifc e peripheral venous defert in the clottin, mechanism ha been as thrombosis or in whom one or more of the pre sumed to be one of the rea ons for the frequent di posin, factor are pre ent hould be u occurrince of thrombo embolic complıcalions pected of a pulmonary emboli m in the occur after childbirth and major urgers rence of a sudden increa ed heart rate th or Slonin, of the blood flow eem to base a without ri e in temperature Cough is u yaliv rather trikino relation hip to thrombus forma an early sign hemoptyst may or may not fol tron Three very common conditions frequently low Pain that accompanies pleural involie associated with intrava cular thrombo is might ment by the pulmonary infarct is especially be mention d here 1 Sloning of the systemic marked in ba al lesions Fever and secondary blood low a ociated with congestive heart pneumonitis often appear two or three day failure particularly in mitral teno ty or fol later Vas se pulmonary embol m may cau e lowin, myocardial infarcton 93 9 as well as sudden death or be folloned by the that ron equent to sudden drops in arterial symptoms of acute pulmonary heart duea e pre ure 2 Local impediment to blood drain Subacute ca es mas pre ent ax tonge tise heart age resulting for example from pre sure upon failure a lety mall emloh m may be ea ily the femoral ve ele by a pregnant uterus or a Derlooked ens and ·44 PERIPHERAL CIRCULATIOV IV IIEALTII AND DISEASE SO onary and mesenteric arteries 42 as well as enough causes considerable repercussions in those of the kidneys, ovaries testes and the the general circulation perirenal and peradrenal fat 43 It is described The most common causes of the condition as a panarteritis with occasional secondary are gunshot or penetrating wounds from other thrombosis 48 Rheumatic arteritis is character causes and the res els most frequently in ized by inflammatory lesions resembling yolved are the femoral brachial and carotid ar those of the pericardium and endocardium teries Locally, the affected limb shous venous with marked reparative processes and carly engorgement increase of surface temperature vascularization of the thickened intima and sometimes edema Peripheral chemic that complete occlusion of the sessel never symptoms may predominate and the toes may occurs *7 despite the rather extensive involve be unduly cold or even gangrenous A ma ment of the vessel vall Kramer and Baylısstchinery murmur and/or thrill are elicited over demonstrated severt exudation and necrotizing the lesion The blood flow in the allected arteritis in rheumatic fever and suggested that limb is vanable apparently reduced in recent severe myocardial damage may re uit from cases but increa ed in old ones, while the blood the circulatory disturbances caused by the c le flow in the unaffected limbs remains normal sions In active cases the involved vessels show The effect on the general circulanon is mani proliferation of the fibrous and elastic tissue fested by tachycardia, eles ation of venous pres similar to that of arteriosclerosis Oddly en sure increased pulse pressure increased total ough there have been no reports of rheumatic blood solume increased stroke volume and car arteritis of the extremities nor hase there been diac output and ultimately cardiac enlarge reports of a no ologic entity attributable to ment if the shunt is large enough symptoms rheumatic lesions in this part of the vascular of conge the heart failure (high output fail tree ure) may eventually develop If the shunt is Traumatic causes of acute artenal occlusion temporarıls obliterated by digital pressure over include pressure from cervical ribs crutches the lesion the pule rate falls (Nicoladon Bran Iracture ctc and other injuries of the ex ham sign) the blood pressure rises the re tremities nous pressure fall, slightly and the cardrac output decrea es with accentuation of capillary Thrombotic Microangiopathy or thrombotic pulsation 4 5 61 63 thrombocytopenic purpura is an acute throm botic vascular di ea e characterized by parnal VENOUS SEGMENT ACUTE PHLEBITIS or complete occlusion of numerous arterioles AND VENOUS THROMBOSIS by hvalıne or granular thrombı with a certain amount of endothelial reaction and absence of Inflammation of peripheral veins as a disea e inflammatory cellular infiltration Clinically entity occurs in the course of various often its manifestations include acute hemolytic ane minor infections It is characterized by tender mia thrombocytopenic purpura fever and 1}} nesa rednese pain swelling and increased defined neurologic de turbances The efrology warmth of the part Inflammation of the sein is unknown The thrombocytopenia and occlu or phlebitis usually recedes athin 24 10 46 sion of vessels are generally held to be due to hours Honever it may persist for several days formation of platelet thromb, but the patho and when it does it is invariably becau e of genesi is not under tood Cases reported in an as ociated thrombus formation producing the literature have been uniformly fatal 53 € the entity known as thrombophlebitis The Acquired (traumatic) arteriozenous fistulae occurrence of phlebo thrombosis or intras as are mentioned here is a form of acute periph cular thrombus without any primary or second eral arterial de turbances because the acutely ary inflammatory changes in the ye scl wall as established arteriovenous hunt of large a clearly defined clinical entity has not been ·47 CHRONIC VASCULAR DISORDERS creas cour e 131 135 the atheromalous plaques undergo hyaline Obliterature arteriosclerosist a manife ta changes and necrosis with calcium deposi tion of generalized arterio clerosi is the mot tion and even bone formation In both condi frequent cause of chronic oſten progressive tions the inhma is the site of maximum in peripheral arterial insufficiency, involving pri volvement and medial changes when pre ent marily the medium sized arterie e pecially are minimal and believed to be econdary This tho e of the lower extremities It affects the male is seen mostly in the aorta and larger vessels population five to six times more frequently and smaller arteries including the coronary than the female 1 199 and occurs in increasing cerebral and renal arteries Arteriolosclerosist frequency with age especially after the fifth is characterized by subintimal hyaline thicken decade 130 Its incidence in the female popula ing and narrowing of the lumen with subce tion however increases considerably after the quent involvement of the mu cularis This as menopau e Diabetes mellitus predi po es to seen to affect the arterioles (arteries of 100 m the occurrence of the disease in the former s cra or less in ameter) of the kidneys pan presence the latter runs a more filminant pleen and adrenals Renal arteriolo clerosis of which there are two ubtypes us Histopathologically obliterative arterioscle seen almost exclusively in hypertension One rosis is characterized by medial sclerosis associated with benign hypertension is char (Moenckeberg s arteriosclero is) with varying acterized by ubuntımal hyalıne degeneration degrees of intimal thichening as a result of su and elastosis or elastic hyperplasia and the perimposed atheromatosis or atherosclerosis other een in malignant hypertension is char Herbut1 7 describes the arterial changes as pre acterized by intimal hyperplasia* with cellular dominantly of a fibrous nature with only mall and subsequent fibrous narrowing of the lu deposits of fat but with frequent vacuolization men and arteriolar necrosist involving the and calcification It would appear then that whole thickness of the vessel wall the clinical manife tations of the disease de In their pure form these various types of pend on the degree of circulatory impairment arteriosclero 19 appear to be distinct from one cau ed by the intimal thickening and po sible another in etiology pathology and clinical intravascular thrombosis and the consequent manifestations However while such pure obliteration of the arterial lumen However forms do occur the two major types charac two facts must be mentioned here First an terized by esenutal calcification - Vloencke athero clerotic plaque may be more damaging berg s sclerosis and atherosclerosis-sery fre in some locations compared to other and ec quently occur together especially in the aged ond the ability of the body to develop collater although the extent of one proces may have als may provide adequate blood supply to body no connection whatsoever with the severity of parts who e primary circulation is completely the other Whether metabolic or humoral fac obliterated by the sclerotic process while on tors or their disturbances may be the cause or the other hand symptoms may occur even in some way influence the production of both when the primary circulation is not as badly or either and whether the presence and extent impaired if adequate secondary circulation of both or either may be demonstrable <lını fails to develop cally by chemical or physiochemical methods Clinically then obliterative arteriosclerosis till awaits elucidation as a disea e entity implies interference with artenal circulation to a degree to be apprecia Syn diffuse arteriolar clerosis diffu e hyperplas ble subjectively (intermittent claudication rest lerosis pain) or objectus ely (di appearance or diminu Syn productive endarteritis, hyperpla lic arte 1o ton peripheral pul es coldne s the ex lo leto s endarteritis fibrosa tremity postural color changes muscular atro Syn arlerolonecrosis necrotizing arteriol tas Syn arteriosclerosis obliterans tic ·46 PERIPUTERAL CIRCULATION IN HEALTH AND DISEASE MINUTE VESSELS characteristic distribution of the exanthemata Exanthemala and enanthemata observed in in the various eruptıse lesers nor for the pre various acute infections are clinical expres dilection for the skin capillaries over those of sions of involvement of the minute blood the mucous membranes in some diseases and vessels in these diseases This might be brought their equal ini olvement in others 106-108 about by toxic injury to the capillary wall Little is known about the behavior of minute (scarlet feser ) 18 with necrotizing lesions vessels in the parenchymatous organs109 111 ex (smallpox) or through bacterial emboli cept perhaps the kidneys zation (meningococcemia, septicemia ty Acute burns permit only an indirect study phod) 11 4 105 The type of invokement of the of capıllary regeneration in the course of skin minute circulation in entirely reversible exan graſting "1 Acute cold injury either at freez themata has not heen clarified as yet despite ing (fro tbite) or subfreezing (trench foot many interesting observations There has been immersion foot) temperatures has been stud no satisfactory explanation for the peculiar and red extensively 109 113 124 Chapter 2 Chronic Intrinsic Vascular Disorders ARTERIAL SEGMENT term that, freely translated means loss of elas Any of the acute conditions discussed in ticity thickening and hardening of the arteries the preceding chapter can become chronic Obuously this description is on the gross path whereby either restitution or ultimate sequelae ology lesel and would be applicable to any of are delayed and symptomatolog, persists for an the various conditions of the arteries where indefinite time this varying widely from case such physical properties are demonstrable to case Such conditions in turn are differentiated In addition there are conditions of the ar from each other histopathologically Voencke terual syetem that are characterized by an in bergs clerosis * considered to be es entially a sidious onset and a chronic course which may enile change is characterized by degeneration of elastic tissue and fibrosis of the smooth mus or may not be interrupted by acute bouts Arteriosclerosis For all the current interest cle in the tunica media followed by calcifica in arteriosclerosis and atherosclerosis and the von producing the gooseneck or pipestem arteries due to localized and ometimes encirc tremendous amount of intensive research be ing conducted to understand the etiology and ling calcium plaque along the course of the essel The intima may show no change or may pathogenesis of these conditions there is not much to show to negate Clifford Allbutt s re how a moderate degree of thickening without however materially interfering with the crew marks concerning causes of arteriosclerosis to the effect that lation This may occur in all arteries includ our path is cumbered with ing the aorta but is most frequent in the arte guesses presumptions and conjectures 15 To ries of the extremities Atheromatosis refers to enumerate let alone discuss the various theo ries and hypotheses would be beyond the scope a condition of the artery characterized by newly formed conneche ti sue and local yellowish of this book suffice at to say that current con thickenings or deposits in the intima composed cepts tend to implicate primarily some disturb of gruellike or pultaceous lipoid material Ath ance in cholesterol (lipid) lipoprotein metabo erosclerosist is a more advanced state where Jim Pathologically honerer there is much an agreement and a brief review of the various Syn senile arteriosclero$14 media sclerost medial cal ino 13 terms and what they signify would be in order 47 3 6 127 Arteriosclerosis is a generic Syn nodular selero is ·49 CHRONIC VASCULAR DISORDERS 1 large arteries and veins may have their share in able one It is apt to gue the impre sion that the late stages of the di ea e Becau e of the it repre ent a defimte di ea e entity which is extensive inflammatory proces involving the certainly not the ca e And furthermore nor ve els and the perisa cular ti sue It is not is the proces, an inflammatory one but rather unusual to see the artery rein and nerses bound productive in type together by fibrous tissue on biopsy in ca es of The various conditions where it is said to long standing occur include47 certain physiologic tates such The disease affects men predominantly as (1) obliterating connective hue prolifera mo tly in early adult life The deep arteries tion of the intima seen in the umbilical and and veins of the legs are the ones u ually in hypoga tric ve els and the ductus arteriosus volved although tho e of the upper extremities in the child oon after birth (2) that een in and other ves els in the body may be involved the ven els of the exual organs in old age and especially in severe ca es 11 11 In about 40% (3) that observed in the uterine ves els after of the cases there is al o early involvement of parturition D. ease states where it occurs in the superficial veins een clinically as painful clude (1) the intimal thickening een in ves red pots or treaks and lasting from one to el in the neighborhood of any form of chronic everal weeks with frequent recurrences thi anflammation as for in tance in the ba e of has been termed uperficial migrating phle a gastric ulcer (2) syphilt where it is sup butus posed to ari e from actie periarteritis caused As is so commonly seen in slowly developing by the spirochaetes (3) cavernous tubercu conditions the patient often does not complain losis of the lungs where extensie thrombosis of any symptoms attributable to the early usually change re els info almo t olıd cords stages of the di ease except in the instances of (4) Ayerza di ea e where there is marked superficial migrating phlebitis The really thickening of the intima with narrowing of the trouble ome ymptoms occur late in the di ease lumen of the mall arteries and arterioles in the and are invariably the con equence of arterial lungs concomittant with dilatation and scle ansufficiency due to marked impairment of the ro is of the main branches of the pulmonary primary channels or to disturbances in the ec artery a ociated with pulmonary hyperten ondary or collateral vessels or both sion and (5) ergotism It is interesting to Clinically thromboanguitis obliterans is very note that adı anced va cular changes produced frequently confu ed with obliterative arterio experimentally in the rat s tail by acral injec clerosis A differential diagnosis between the tions of ergotamine are inde tingui hable mor two conditions is therefore nece ary (See phologically from those een in thromboang) Table 1) itis obliterans in man 1 3 It may be only a Cases of thromboangulis obliterans and ob matter of time when as in the ca es of TAO literative arteriosclerosis have been called and OAS better and more definitive tudies from time to time endarteritis obliterans of these conditions will develop a more appro However with the more extensile morphologic priate term for each of them and the term en studies of the e conditions the practice has darteritis obliteran having outlıved its u e been gradually abandoned fulnes will be relegated to the pages of lous Oblteratie Endarteritis Semantically this tory de ignation connotes an inflammatory proces Another intere ting entity that might be involung medium ized or small arteries mentioned here is Temporal Arteritis This with occlusion or narrowing of the lumen of condition was fir t described by Hutchin on the ve el The inadequacy of the term to de and later more clearly by Horton Vagath nole a pecific no ologic entity becomes ev and Brown 1 & who sugge ted its term des dent immediately As Boyd points out the ignation Sub equent ca e report however es terni although in common u e is not a desir pecially of evere fatal ones have hown that ·48 PFRIDJIFRAT CIRCULATION IV HEALTH AND DISEASE 14 phy trophic changes in the kin and its ap year old man who had an amputation after a pendages ulceration and gangrene) It might 12 year symptomatology a condition Von Win indeed be well to refer to this clinical symptom Isarter called endarteritis and endophlebitis complex as sclerotic peripheral arterial in ufli of the le. Such changes are characteristic of ciency in tead of obliterative arteriosclerosis, the condition we nou call thromboangutis ob which neither de cribes accurately the patho literans 141 Many reports in the early literature logic changes nor sugge ts whether or not clin that appeared subsequently eemed to deal with real signs or symptoms may be expected thromboangulis obliterans In 1903 Eising' In mo t ca es it is po sıble to ascertain other in a case reported before the New York Patho evidence of arteriosclero is or athero clerosi, logical Society, directed attention to the aggra such as aortic sclerosi arterio clerotic heart saling influence of smoking on the disease 16% disea c coronary di ease cerebral arterioscle In 1908 Buerger s first paper on the pathology Tosis or nephrosclerosis Since arterio clerosis of the disea e was publi hed uggesting the is usually well advanced when it inches the use of the term thrombo angutis obliterans' cerebral arteries the retinal arteries which con and in 1909 Parkes Peber, in England re stitute a part of the cerebral bed may possibly ported similar studies 145 provide a clue to the status of the vascular free In his book 116 Buerger described in minute as a whole detail the gro s and micro copic findings in the While pathologically, obliterative arterioscle disea e as well as its Various pathologic and rosis is usually bilateral the non uniformity of clinical tages and he discus ed his concept of the degree of athero clero is and the inconstant its pathogenesis Since these classic descrip occurrence of atheromatous thrombolic occlu trons thrombo anguitis obliterans' has been son with its equclae may cause the manifes establi hed as a definite clinical entity often tations of arterial insufficiency to be evident called Buergers Disea e in recognition of only on one ide to the total exclusion of the that scientist « excellent contribution to its other pathologic identification Thromboanguts Obluerans * This is the As Buerger pointed out the essential le son next most frequent cau e of peripheral arterial was not a degeneralne process but an inflam Insufficiency Samuels resies of this di case s mation of the ressel wall with con equent hi tory-which has been ob erved for rent thrombosis involving both arteries and rein turies- series as a detailed reference 13r The The lesion occur egmentally with the throm firat indication that the disea e was recognized bus occluding the vessel completely in as a eparate and di tinct entity may be as part with intersening normal portions which cribed to Balling who in 1830 alluded to a are free from lesion of any detectable degree juvenile type of gangrene 13 In a report on Ab ence of suppuration and necrosis is charac lus study of pontaneous gangrene in 1872 teristic The intensie organization of the Leffas advocated a con ersative treatment of thrombus and ubsequent fibro is with the can the condition 139 An inflammatory proces in alization that may occur to ome degree might the arteries with involvements of the intima guse the impre sion of a thickened intima in and ub cquent thrombosis and obstruction the cut section Amore critical examination of was described in 1876 by Quinche 139 In that the lesions with the use of ela tic tissue fat and same year Friedlaender u ed the term Ar calcium stains howeser easily determines the teritis Obliterans to refer to an inflammatory trup nature of the obliterate proces In any lesion of the pulmonary le els 110 It remained event calesfication in anioked sessels in elderly for Von Winiwarter in 1879 to make the first ubjects does not rule out the disease since detailed de cription and illa tration of the ar superimpo ed arteriosclerosis is very frequent terial and enous changes in the leg of a 57 in the e cases The medium sized and ma!! Syn Buergers Di ca e Iresenıle gangrene kes els are the ones chtefly in olied but the ome ·51 CHROVIC VASCULAR DISORDERS from the artery to its accompanying vein and increased pigmentation as well as in through an abnormal opening or channel with creased hairıness of the limb There is in out passing the capillary bed it may be con creased warmth of the part Thrill and bruit genital or acquired The congenital type is usu are easily detected over the lesion Due to the ally multiple and re ults from failure of the resulting enous insufficiency stasis ulcers are vessels to differentiate and separate completely not uncommon complications during their embryonic development from a The effects of a sufficiently large arteriove common anlage This may occur in any part nous shunt upon hemodynamics are mani of the body but is most frequently seen in the fested by an augmented venous return and extremities Presumably due to increased cir elevated venous pressure increa e of blood culation in the involved extremities there is volume and cardiac output and sub equent increased growth of the limb including the dilation and hypertrophy of the heart which bones and not infrequently it is out of pro might eventually lead to high output failure portion not only to its opposite member but with the symptomatology described above to the rest of the body as well This condition Diagnosis of the condition is established by produces what is known as giant limbs In the history of the original injury the above creased growth of hair and undue warmth physical findings arteriography and by the of the part are commonly observed Varicose fact that oxygen saturation of venous blood veins are present as a rule and their pre ence taken from the involved limb is considerably in early life may erve as a lead to the diag higher when compared to that taken from the nosis of the condition Ulceration and gan normal side grene may occur as a complication of the The so called collagen or fibrinoid dis condition presumably attributable to chronic eases must be mentioned here because of the venous <tasis and to relative arterial insuffi distinct and pathognomonic vascular lesions ciency due to shunting of blood away from ome of the di ea es of this group parts distal to the lesion I olyarteritis nodosa* 173 17 is considered to As mentioned earlier acquired arteriose be a primary vascular disea e occurring fre nous fistulae are traumatic in origin When quently in males e pecially during the third sufficiently large vessels are inyolsed normal and fourth decades There is fibrinoid degen hemodynamics are interfered with rather ab eration involving medium sized and small ves ruptly the repercussions in the cardiovascular sel as well as capillaries Irregularly di po ed system are dramatic and may be of serious segmental fibrinoid necrosis of the media as nature If the acquired shunt is not corrected sociated with leukocytic and eosinophılıc infil and the patient survises the acute stage with tration of the ve sel wall is the basic pathologic its immediate complications the circulation ul picture There is subsequent involvement of timately adjusts to it and there ensues a chronic the other vascular coats with intravascular compensated state where the pathophysiologic thrombosis recanalization aneurysm forma effects of the vascular short circuit are present ton granulation and fibrosis with healing tak to a degree dependent on the size of the defect ing place by scar trasue formation Vessels These effects may be easily demonstrated in throughout the body may be involved and the our discussion we shall limit ourselves to ar pre en ing clinical picture depends upon the or teriovenous fistulae occurring in the extremi gan or organ sistem most affected at the time Insolvement of the arteries of the extremities The involved extremity increa es in size and pre ents with symptoms of arterial in uffi length (if the fistulae were acquired before ciency joint and mu cle pains Cutaneous the closure of the epiphy is) Extensive se manifestations may include subcutaneous nod nous varicosities may be well yasible or easily Syn periarteritis nindo a polyanouitis panarteritis palpable There may be some degree of edema necrotizing anguiti een in ties ·50 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE Table 1 Thromboangtitis Obliterans Obliteratise Arteriosclerosis 1 Ate and onset of symptoms Young adult life 20 40 years Usually over 50 years may also occur however in young adults especial, diabetics 2 Ser I redominantly in males Predominantly in males in young er age groups At past 60 oC currence in females not unusual especially in the presence of dra betes mellitus 3 Site of inyolvement Forst lower extremities Upper extremities may le involved in advanced and severe forms of the di ea e Small and medium sized Tessels usually insolved Large arteries or veins involved only in advanced cases Almost excluskely the arterial tree of the loner extremities In volvement of large artertes com mon 4 Occurrence of superficial or migrating thrombophlebitis" Occurs un 30% of cases Does not occur This must be dif ferentiated from secondary throm bophlebitis of superficial varicose Seins which might le mistaken for migrating phlebitis None 5 Arterial calcification (by x rays) Frequent 6 Complicating di eases a Hypertension Incidence not greater than in general population Frequent especially sy tolic hy pertension b Diabetes Vellitus Incidence not greater than in general population Frequent u wally associated with a fulminant and severe course of the vascular disease None c Other evidence of arterio sclerosis Frequent eg aortic sclerosis of retinal arteries presence of ar cug or circulus sensus arterio sclerotic heart di ease cerebral arteriosclerosis non obliterative sclerosis of other peripheral or terles es the brachial and ra dial arteries the condition is a widespread one inyolving the media intimal necrosis or intravascular mo t of the vessels of the body Characterı tic thrombosis Insolement of the adventitia and lesions een in the temporal arteries show a even the periarterial nerves occurs in severe non suppuratis e granulomatous inflammation cases Healing takes place with granulation with a peculiar de truction of the elastic fibers and fibrosis 127 of the internal elastic lamına uith giant cell Arteriol enous fistulae 57 € formation 157 1 8 Tith extension of the proc a condition affecting the larger arteries and ess there is destruction of the mu cle fibers in veins where arterial blood 18 shunted directly 159 17 This is ·53 CHRONIC VASCULAIT DISORDERS and in tips Acro clero is follows ooner or later u es of the hands and foct Clinically the con ome ca es a clinical picture develops dition pre entit elf as an unevenly mottled that is not easily di tingui hable from general blue or reddi h blue di coloration of the in ized cleroderma The upper extremities are oled parts which is intensified by expo ure involved long before the lower to cold It is often as ociated with ubjective While the entity has previously been con and objective coldne s hyper hidro is is sidered a spa tic di order due to primary common Interpretation of the clinical signifi changes in the autonomic nervous sy tem the cance of uch vasomotor phenomena is difficult investigations of Lewis Pickering and other ince they are often found in per ons mani indicate the likelihood of its being rather a fe ting emotional in tability primary vascular di order affecting small ar Luedo Relicularis* 185 a peculiar con teries Ca cs exhibiting secondary Raynauda dition of unknown etiology characterized by a Phenomenon discus ed under primary nerv reddish blue mottling of the kin It eems as ous disorders do not ever eem to progress sociated with proximal ob truction or pasm to true Raynaud s di ea e Thus it would ap of small arterial branches and with di tal ca pear rea onable to a ume that the va cular pillary dilatation The condition is per i tent changes (fibrotic thickening of small arteries) not dependent upon environmental tempera ob erved in Raynaud s di ea e are primary ture changes and is occasionally a ociated and not a sequela of prolonged or repeated with superficial ulcerations grastic vascular contraction Cuts Warmorata100 ) is a term applied to Erythermalgra* 19 195 19 a vascular di or a condition characterized by blun h marbleiza der characterized by abnormal vasodilation in tion of the kin on expo ure to cold Its ap the extremities cau ing redne s and conge pearance is very imilar to luedo reticularis tion of the im olved parts with elevation of the but di tingui hed from the latter condition surface temperature as ociated with burn by the fact that it occurs and di appears tran ing and painful en ations The condition is siently depending upon the environmental provoked and aggravated by dependency and temperature The condition is not demonstra exposure to heat The patency of peripheral bly related to vascular disease ve els is unimpaired with preservation or Frostbite 13P 195 Exposure to extremely even increase of palpable peripheral pul a low temperature obsou ly may cau e death tions Clinically two types are recognized an idiopathic type the etiology of which is of ti sues by freezing of the protopla m Ex unknown and which occurs in othersi e posure to somewhat higher temperatures healthy individuals who do not manifest any (11 F) however is followed by marked nu evidence of vascular or nervous disorders and tritional impairment of the tissues ufficient to cause their death and to lead to gangrene Usu a secondary type where erythermalgia is as sociated with other di eases eg polycy themia ally the u e of the term frostbite is limited to vera generalized sa cular disease organic gangrene following such exposure in ca es neurologic di eae or heary metal poi oning where there was no preexi ting arterial dis ea e It tand to rea on however that rela In the primary or idiopathic type where there is ab ence of vascular in ufficiency complica tive arterial in ufficiency which otherwie tions uch as ulcers or gangrene do not occur may remain undetected renders a person much more liable to damage through expo ure Acrocyanosis18 19 199 is another vascular to cold The acute pha c of the condition is di order who e etiology is unknown It is characterized by intrara cular thrombo is in characterized by sa o pasm of the arterioles volung arteriole venule mall arteries and and dilatation of the capillary and venou plex Syn Inedo racemo a liedo annulan a phyxia Syn erythromelal, a reticulares ·52 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE eases ules erythematous cruptions bullous lesions thickening of blood vessel walls, occasionally purpura petechiae ledo reticularis necrosis associated with thrombo is has been described Disseminated lupus erythematosus similarly is Certain capillary changes have been described characterized by lesions occurring in many or in the skin of these patients that are indrs gans particularly intoling the blood ves els tinguishable from the giant capillary loops Unlike polyarteritis which pre enls n picture observed in patients with Raynaud s di ease ? ' of inflammation its lesions are mainly degen Many patients with dermatomyositis and es erative Furthermore it affects only the very pecially with seleroderma also manifest symp small branches of the vascular tree namely the toms of Raynaud s disease It is likely that such arterioles and capillaries 'The le ions charac capillary changes are demonstrable only in terized by widespread fibrinord degeneration those ca es vluch are afflicted with both di with minimal leukocytic infiltration, are also not confined to the ses els but are equally de There is an increasing tendency to include mon trable in the surrounding tissues All the rheumatic fever and rheumatoid arthritis arteriolar coats may be insolved with marked among the fibrinoid diseases The vascular intimal thickening True thrombosis however involvement in rheumatic leser has been de is rare Clinically the principal lesions are cu scribed earlier in the chapter The vascular laneous cardiac or renal The initial skin le changes in rheumatoid arthritis are not char sion in typical cases is an erythematous acteristic However a fibrinoid change in butterfly patch acro s the bridge of the nose the fiber bundles of the thickened synoual although in many in tante cutaneous lesions membrane may in a few instances be scen may appear el en here without the initial patch with the picture of the rheumatoid nodule In the heart there might be an atypical ver This consists of a vascular granulation tissue rucous endocarditis (Libman Sacks syn the arteriolar walls may be found to be in drome) causing cardiac decompensation flamed or necrotic and to contain fibrinoid which may be indi tinguishable clinically material dascular basis as the starting point from ubacute bacterial endocarditis In the for the morphogenesis of the nodule has been kidney lesions in the glomerular tuſts appear postulated due to the occurrence of the fibrın wire loop capillaries and focal necrosts oid change and necrosis in relation to the sea cau ing signs and symptoms of glomerulone el suggesting that a necrosis producing phritia Diagnosis is made by the finding of agent is fluid borne into the ti sues from the L E cells (neutrophils with engulfed ses els 180 181 Advocates of this theory also large round homogeneous basių staining bod believe that while arteritis found in this dis ies) in the bone marrow or peripheral blood ea e is not histologically pathognomonic it is by the demon tration of the L E phenome possibly a specific manifestation of the disease or by biopsy This disea e is much more They base this opinion on the description of frequent in females and its incidence is great arteritis in strated mu cles (in 10% of biopsy et in the wecond to the fourth duades of pecimens18 ) and the excluşile insolvement of life 47 178 178 It is noteworthy that disease en the very small arteries and capillaries Similar tities such as LED in which the inı olement ascular lesions have been demonstrated in of the va cular system is not as prominent a other tissue including the neries183 and feature may present 1s peripheral vascular di order with the signs of ouclusile di case Rainaud s Diseases 101 is characterized by and even peripheral gangrene This is e pe frequent attacks of udden blanching in scu cially o in the pre enct of severe anemia eral finger or in the whole hand elicited by Dermalomyositis and Scleroderma do not expo ure to cold (Raynauds Phenomenon) pre ent dacular lesions of any pathognomonic and followed soon by the des elopment of mul significance Inerea e in connectne tı sue with tiple mall gangrenous ulcerations at the finger as non heart 18 ·CHIROVIC VASCULAR DISORDERS 55 and more lose its Tenous pitting character does not reflect the presence of deep venous and become brawny There may be marked disease it is probably the result of postural collateral enlargement of the superficial ve strain in association with congenitally incom nous system or complicating ulcers may de petent or weak valies and/or a congenital velop weakne s of the venous wall (Ledderhose) Recurring thrombophlebitis has been de MINUTE VESSELS cribed in the literature 03 It appears to be of Trench Foot * 09 10 Prolonged exposure to an infectious nature but the exact mechanism is low but not freezing temperatures especially not known The superficial aphenae are most under damp or wet conditions can cause se frequently involved vere damage to the kin blood ve sels or nerves The smaller veins may be affected second of the expo ed upper or lower extremities Ex arily in syphilis Similarly secondary involve posure to cold causes vasoconstriction and da ment of the veins may occur by extension of a mini hed blood flow to the extremities Per tuberculous process from neighboring tissues sistent tissue anoxia in turn causes damage Migratory Phlebitis This condition is char to the capillary walls and vascular occlusion acterized by thrombophlebitis of short seg In the chronic pha e of the disease 116 despite ments of many peripheral and visceral veins recanalization of thrombosed blood vessels or with minimal inflammatory reaction These development of collaterals that obviate tissue are not involved simultaneously but rather in death and necrosis a residual impairment of a skipping fashion The veins of the extremi blood flow regulation and consequent difficulty ties the inferior vena cava and its tributaries in adjusting to temperature changes persist and the dural sinuses are sites of predilection A symptom comparable to intermittent claude Small red tender nodules along the cour e of cation in cold weather is also common and the vein may be seen with the peripheral le in some cases signs of occlusie vascular dis sions The etiology is unknown Some cases ease are evident are associated with carcinoma of the pan The presence or absence of pre existing ar creas 04 As mentioned previously a superfi terial di ease at the time of exposure is a de cial migrating phlebitis may be the pro cisive factor in the clinical course of the re drome of thromboangutis obliterans Focal in sultant condition By and large where there 19 fection has been invoked as the cause of this impaired arterial blood flow to start with there form of phlebitis 136 Obviously simple phle will be little tendency to recanalization and bitis occurring in varicose veins may partake tissue death will ensue where the peripheral of this characteristic Another variety of mi circulation and its regeneration were perfectly grating phlebitis that has a special predilec normal one finds the signs of rapid canaliza tion for such visceral veins as the lungs heart tion in most instances in the chronic phase of and brain has been reported in the litera the disease one may be guided in the clinical evaluation of the patient by the principle that Taricose I eins As is the case in post phle the more discrepancy there is between the bitic occlusion of deep seins collateral en intensity and duration of exposure and the largement of the superficial veins may also oc everity of the le ion the more likely it will be cur in any condition where there is obstruction that the patient had diseased blood vessels al of the senous flow eg in pregnancy pelvic ready when he contracted the thermal injury and abdominal neoplasms These must be dif the easier restitution occurs the more likely ſerentiated from superficial varicosities men it is that the subject had a healthy vascular tioned above which represent collateral cir system before the exposure culation in response to deep enous obstruc Telangiectasia 17 199 13 a term tion The ordinary run of the mill vanety Syn immersion foot immersion hand sh Iter foot ture 0 07 01 111 ·54 CERITERAL CIRCULATIOY IN HIEALTII AND DISEASE 199 erythema small veins while at presents the signs of oc months, however permanent sequelae esen clusile arterial disea e the carly trophic tually appear in the form of residual scars changes are of a severity exceeding what one from the ulcerations and atrophy of the lin would expect from the degree of arterial in and subcutaneous tissues at the sites of involle volvement compired with chronic occlusive ment arterial disease 1 It is uncertain whether the Erythema Ab Igne intravascular thrombosis that occurs under led to chilblains is due to the opposite cau e 02 the virtual paral these circum tances is due to the sustained namely heat The anterior surface of the legs vasoconstriction and vascular atasis or is sec is usually involved although other parts of the ondary to the necrotic tissue changes body which have been exposed to undue heat Pernio • 18 199 This is a condition which may similarly present the lesions It is seen appears to be another reaction of the peri in cooks stokers and other persons who e oc pheral blood ve sels upon exposure to cold cupations expose them to direct heat from it is not known whether it represents a variety stos es furnaces and the like The lesions are of frostbite However, most writers classify erythematous with varying shades of red at the two conditions separately and this might first diffuse but ultimately presenting a reticu be the bet thing to do until the e conditions late pattern Pathologically va odilatation oc are better understood Chilblains are said to curs and with continued exposure and pro occur in persons having feeble peripheral cir gression of the condition secondary shin culation' The acute form is encountered fol changes take place including pigment depos lowing expo ure to cold at affects the exposed its in the involved areas Residual pigmenta parts of the body (hand feet shin ) and ap tion may persist even after subsiding of the pears as an erythematous patch u ually bi lateral and symmetrical blanching on pres Aplasia or llypoplasia of peripheral arteries sure cold to the touch and attended by ten are rather rare congenital conditions They derness itching and burning There is infiltra are almost invariably bilateral General evalua uon and edema of the affected part In more tion of the patient is necessary to differentiate severe forms a purpura like ra h may be seen the condition from acquired arterial do ease and swelling and bleb formation are not un The determination of the presence or ab ence common Subsiding of the condition and even of signs or symptoms of vascular insufficiency tual clearing of the lesion is the rule although is of prime importance Where any doubt re a residual pigmentation in the area may re mains angiography establishes the diagnosis main VENOUS SECMENT If the susceptible individual is repeatedly er Venous thrombosis (thrombophlebitis) may posed to cold the chronic variety may be pro resole completely ( restituho ad integrum) duced This form is characterized by season Even in cases with several recurrences of deep ally recurring dermatitis in the same expo ed thrombophlebitis there may be intervals of parts of the body as tho e inoked in the acute complete recovery In about half the ca es form The lesions are also een as erythematous however there derelops a state of permanent patclips pre enting various shades of red yet deep venous blockade characterized clinically cold to the touch and with much of the same by putting edema heas iness of the limb and subjective manifestations More selere forms impaired funrtional capacity with pain on ex are hemorrhagic superficial ulcerations being ertion This may conveniently be called post not uncommon There is usually subsiding and phlebunt syndrome It may occur after the clearing of the le sons during summer months fir t bout of thrombophlebitis or after a num with repeated recurrences during the cooler ber of later bouts Over the years a lymph stasis supertenes and the swelling may more * Syn, chilblains en thema pernio ·57 CHROVIC VASCULAR DISORDERS # rarely 19 30 which makes it compre sible The e casernous It is not continuous with the normal channels paces may directly connect with the larger but consists of a closed sy tem of freely inter channel in the systemic circulation in which communicating spaces lined by flat endothe ca e they u ually behave like an arteriovenous lium and eparated by thick epta of connec fi tula Valignant degeneration may occur tive tissue A cytic lymphangioma may pre ent as Glomus Tumor 11 18 Glom are physio a frankly fluctuant mass due to the fact that it logic structure prevent in large numbers in const ts of smaller and larger cy tlike struc the kin of the fingers and toes in maller tures lined by endothelium and filled with numbers in the hands and feet They are sub lymph cutaneous arteriovenous anastomo es with non Although generally benign tumors of lym myelinated nerve fibers and connectise tis ue phatic channel may in the course of extension enclo ed by a mooth mu cle coat The e neuro or enlargement produce various clinical syn myo vascular structures dromes due to pressure on vital tructures erve as the body s thermostats and play an important role in They may cau e pressure on and obstruction peripheral circulation and heat regulation of of vascular channel to which they are usually in intimate anatomical relation the body A glomus or everal of them may un Malignant tumors80 1 arsing dergo benign hypertrophy and hyperplasia from producing small rounded elevated firm red to the blood ses els are called hemangio ar comas blue extremely painful nodules 05 to 2 cm in those arising from the lymph vessels diameter The e may be found in various lymphangio arcomas parts of the extremities but mot frequently The hemangio arcoma † 19 malignant a beneath the nails va cular tumor that is usually large all defined Hemangiopericytomas 16 17 18 are sim often hemorrhagic and moderately firm in con ilar to the glomus tumor except that here thesistency It is composed of intercommunicat glomus arrangement is not pre ered they ing vascular channels lined by atypical endo thelial cell The e endothelial cells may al o are more varied in their location and are quite prone to become malignant exist as sheets within the stroma or may be found on heaps in the Vascular lumina Lymphangioma 11 Benign tumors of the lymphatic channel are called lymphangi Kaposi's Sarcoma [ +7 109 omas like hemangiomas they are congenital especially intere ting form of hemangiosar being misplaced Temnants of fetal tissue that coma that mostly occurs late in life While it have developed into lymphatic networks or may arise in almo t any part of the body the paces which are usually not continuous with initial lesion u ually onginates in the kin the normal channels The term simple lym of the extremities The e lesions appear as phangioma has been used to designate loral circumscribed discrete or grouped irregular dilatations of lymphatic sessels as well as anas red maculo papular lesions of pinhead to tomo ing mall and medium sized ren el sepa bean size gradually they acquire more hemo rated by thin connectile tissue trabeculae siderin pigment and become purplı h and even The e lymphangiomata are mall warty excres tually black Purpuric le ions with a cular cences compo ed of lymphatic capillaries and thrombosis al occur The process starts with diagnosed by their lymphatic contents lymphocytoid cells of Marchand and other ves Soon the le ions exhibit A cavernous lymphangioma presents it ell sel "all element as an ill defined compre ble ma , of varying Syn cyt chye oma size it may be located anywhere in the body + Syn bemancio ndothelioma Syn glomang oma ang oneuroma painful sub Syn multiple id opathi hemorrhagic sarcoma ulane us nodule a giomyoneuroma Idiopathic multiple pigment sarcoma hapo i 13 1 This 1 an ·56 PERIPHFR IL CIRCULATIO IV HEALTH AND DISEASE € Sias a per chest с used to designate abnormal dilatations of cap Heredilary hemorrhagic telangiecta ullaries and other minute superficial blood This hereditary or congenital condition ve sels Such dilatations may be hereditary or į characterized by the presence of groups of acquired developing during life The follow thin walled, abnormally dilated capillaries and ing five common clinical types ob erved in small seins found in the kin but mo tly in the skin and mucous membranes have been mucous membranes The lesions are mall tudied by capillary micro copy and described pinpoint to a few millimeters in diameter but in some detail are multiple and usually coale-cent Bleeding Simple telangiectasias Seen as either occurring spontaneously from some lesions red or blue in color not rai ed above the skin frequently gives rie to considerable blood urface non pul atile varying in length and loss and marked anemia diameter and involving a single portion of a les el They are found especially on the no e Vascular Tumors 141 131 Benign tumors and upper cheeks and occasionally on the up of the vascular system are called hemangiomas Primary tumors of the vascular sistem may af ſect blood flow mechanically by pressure or 1 Arborızıng telangiecta ias Frcept for obstruction or through the e tablishment of the presence of ome branch formations thes abnormal shunt They may insolve the ses are similar to the simple type in characteristics and di tribution sels in any organ or tis ue of the body Bath po sıbly fest exceptions vascular tumors are Spider telangiectasias They present histologically similar to one another all being as a rule a pul ating central rai ed bright red composed of va cular channels and classified portion from which emanate fine radiating only on the basis of the size and gro s appear branches that mea ure one to two centimeters ance of the lesions They result from the fail in diameter and a bright pink capillary flare ure of the embryonic angiobla ts to form the between the radiating es els By the exertion normal va cular channel of slight pressure with a glass slide one can The capillary hemangioma is small rang easily demonstrate pulation which in many ing from a few millimeters to several cent: instances may even be palpable Pre ure on meters in diameter it is bright red and made the central spot with a fine point will cau e up of thin walled capillaries It is congenital immediate blanching of the whole le ion They but becomes clinically noticeable at later age occur chiefly on the upper limb When it undergoes retrogressive changes it i che t and back and at the sites of the simple called sclerosing hemangioma and arborızıng telangiectasias They are fre The portwine tain or ner us Nammeus 14 quenth observed in patients with cirrho is of pink to purpls h flat and blotchy composed of the liver or with nutritional deficiencies and thin walled dilated capıllaries in pregnant women They also occur however Spider angiomas are really telangiectasias in healthy induudual and may be found in and not tumors they have been described in a as ociation with other va cular lesions previous ection d Parular telangiectasias They The cavernous hemangioma is the biggest round harply circumscribed dark red papu type of benign sa cular tumor it usually oc lar cugmata varying in size from pinpoint to curs in the deeper portions of the skin and sub cutaneous trssues for which reason it appears 10 cm diameter Vicroscopically they are as an ill defined colorle, or blur h ma I een as accumulation of tortuous capillary con 1 ts of a ma s of intercommunicating loops with multiple and curly crossing giving cavernous paces lined with endothelial cell the loop an almo t grapelike appearance They are most frequently een on the trunk espe + Syn ſamtal sold telangiectasja Ren lu O ler Weber disea e cially in elderly persons the upper are ·TERITIONS DLOOD FLOW 59 Table 31 Incr Influence of a Standard Vasodilator Semulus (Gibbon Landis I rocedure) on the Temperature and Blood Flow of the Lower Extremities Under Ba al Conditions After Idaption to an Ensironment of 20 C and 55% Humidity Basal Readings Varimum le por e Dature of Re ponc Patient Temp Blood Flow Temn Blood Flon Temp C Blao 1 Flow Initials {m}/100 ml fmt/100 mi (l/100 nu! t# /sn) łowce/min) ti ve/mmn) HN 210 69 320 85 80 Incr 18 VS 215 43 25 Incr 30 Incr 79 1.3 130 8 325 13 Incr 95 Incr 39 MC 5 67 3 5 100 Iner 100 IDCY 33 21.5 166 280 35.5 65 Incr 189 VE. -40 39 760 4.3 Sacr 0 Incr EH 20 10 (5 25 5 Incr 2.5 Incy +8 AR 265 61 310 200 Iscr 25 Incy 36 210 55 330 Incr 90 Iner 36 25 107 310 353 Incr 1.5 Incr 52 ST 905 136 0 257 Incr 35 Iner 121 CC 910 41 45 Incr 85 incr AValus 81 1299 Incr 489 Incr 3.5 3 191 and in polomyelitis are fully explained ls cases with peripheral nerve injury without disuse they are seversible and not a sociated complete selerance of the nerse which leads urha altered vasomotor resport es 10 an arritation rather than a degeneration of In Syringomyelia and in certain ca es of the posterior root system the sequelae a burn tabes dorsali an element of sen ory di turb ing pain gate the name which should really ance is added to disuse leading sometimes to be cau talgia In recent years the term das 1a cular changes econdary to trauma -3 been widely applied to all kinds of all defined The effects of tran ection of the cord upon complaints most of them probably represent blood flow and sasomotor responses eem to ing conversion symptoms be enurely dependent upon the level and com 4 Disturbances of the Autonomie pleteness of the lesion 9 which no factors Nervous System The effects of sympathec determine the degree of interruption of sym tomy upon peripheral blood flow and upon pathetic pathwave 34 vasomotor responses are of great interest Ob 3 Peripheral Nerse Lesions Section or Literative arterial disease of the lower extremi other injury of a peripheral nerve leads to red tres does not es entrally alter the reflex vaso dening and warmth in the upplied Ismb As motor respon es to warming although basal Sewit1 «o clearly analyzed it The e are the ret How is con iderably lower than in young expected equels of imple sympathectomy healthy adults while subjects of comparable After 2 to 3 weeks however there is a change age groups without demonstrable vascular dis to the oppo te the lumb becomes first cold ea e show intermediate values and pale later slightly cyanolic If regenera it is of interest that respon e of surface tem lion of the injured nerve is pos able the e find perature to warming is delayed and takes place ings may gradually ds appear again II de 19 A more gradual la hion in arteriosclerotic nervation persists there may en ue secondary subjects (See fig 2 ) w rular changes 18% If there is loss of ensa After sympathectomy rest flow and surface tion injuries may lead to evete sequelae re temperature are increzed 37 * Most work minding one of the indolent ulcers ers agree that sympathectomy alter, 18yomo syringomyelia tor respon es -36 { 10 There is sugge fixe Crusalgia is a term originally coined for eusdence that the neusal mechanism dominates een in ·58 PERIPHERAI CIRCULATION HEALTH AND DISEASE changes characteristic of capillary or caser and mot any of the viscera notably the liver nous hemangioma Infiltration of the sur intestines lungs and spleen It is not e tab rounding tissues muy produce an elephantiasic lished whether these represent meta tatıc le appearance As the conditon progres es the sions or multiple primary foci Hemorrhages lymphocy loid cells become replaced with elon and sub equent anemia are common abo in gated spindle hke cells that fu e with and re stances of hemolytic anemia some of which emble endothelial cells producing a are presumably due to lesions in the spleen matous appearance Sooner or later nen le or in the bone marrow have been reported sione appear in other parts of the extremities The course is fulminatin, in come and pro as well as in mucous membranes lymph nodes tracted for years in others arco Chapter 3 Alterations in Blood Flow Due to Extrinsic Causes TRAUTATIC INJURIES crea e in basal flow regularly ob ered in the Traumatic injuries, with or without loss of paralyzed cxtremities of hemiplegic patients continuity of the kın or tissue substance of does not seem to bear any relation to disuse my suſicknily extenere or serere, inescapably in la omotor respon es to phy cologic and phar olie the various va cular channels in the af macologic stimuli are preserved fected extremity This may result directly Vuch attention has been paid to alterations from the accident or from any supervening in in cerebral blood flow, since a great number of ſection Arteritis phlebitis and arterial as well cerebral le ions may be traced etiologically to as Senous thrombo is may des elop Second la rular dhea_e 30 31 Arteriosclerosis and ary arterial and venous pasm frequently de Irypertension have a wide pread and widely velop under these circumstances and occur in known impact upon cerebral circulation-3 the blood vessels directly involved by the in and brain metaboli m-1 and thus necessarily jury as well as other ve sels in the immediate upon brain functions It is accepted knowledge vicinity This may be due to a reflex increase that most strokes are etiologically due in vasomotor tone in the body s effort to con cular di ease 39 The occurrence of cerebral trol hemorrhage or to the accumulation of arterial pasm has been more controversial metabolites resulting from the circulatorv im than that concerning “peripheral arterial pairment Segmental arterial spasm has been pasm” It eem, that the evidence is in favor ab ered at the operating table even under of the existence of such a clinical entity -3 24 minimal traumatic conditions ? although perhaps not as clear cut as those con cerming arterial channels in the extremities it DISEASE AND INJURY OF THE would be outside the scope of this book to dis NERVOUS SYSTEVI cuss these extremely intere ting problems The 1 Cerebral lesions (cerebro vascular ac insolement of cerebral circulation by a rarer cident tumors) The e do not seem to influ type of vascular di ease such as obliteratne thromboangute and the implications of the ence peripheral blood flow and sasomotor re occurrence of congenital and later developed ponkey 10 any great extent unles one of the aneurysm of cerebral se sels may al o be men 1a omotor centers is insolved As a matter of fact marked sa omotor alteranons occurring in a case with a cerebral lesion strongly sugges! 2 Lesions of the Spinal Cord Blood a hypothalamic involvement 28 The slight in flow changes obseried in muscular dystrophy tioned in passing ·61 ALTERATIOS Y BLOOD FLOW Shun Tenip e'c 351 201 D S., 22yrs g (Normal) GUP eines -10 -5 Startea io s's 20 as sods to 45 šo s's 60 'C 25 201 4 N, 62yrs a (Arteriosclerotic) FIL 2. SKI TEMPERATURE RESPONSE TO GL PROCEDERE. AB, 47 yrs BI Flow (nl/100 ml/min) 20+ Right Side (non sympathectomized) 204 Left Side (sympathectomized) 15 15 JO lo 5 5 Time (min) 30 15 15 30 45 60 GLP started 30 15 1 15 30 45 60 GLP started Skinc Tamp 351 404 30 351 25 30 20+ 25+ Fic 3 RESPONSE TO GL PROCEDURE ·60 PFRII JIRAL, CIRCULATION IY HIFALTH AND DISEASF Tablc III Influence of a Standard la odilator Sumulus (GL Procedure) on Temperature and Blood Flow of Lower Extremity Under Basal Conditions After Adaptation to Fnvironment of 20 and 55% Humidity A NORMAL SUBJECTS (YOUNG ADULTS) TEMI ERATURE с BLOOD FLOW (Ml/100 ml tissuF/MIN) Patient Control I eading Marimum Response Basal Flow Manmum Response 350 355 IW SD SI MII DS EC AO SP AS EG 285 240 220 210 225 270 275 400 315 36 5 315 335 33.5 330 335 Average aluc 136 91 32 240 209 105 160 167 145 94 13 79 177 180 70 254 30.5 148 216 189 230 214 960 215 208 1991 BEI DERLY SUBJECTS (NO DEMONSTRABLE VASCULAR DISEASE) FK 25 0 950 230 25 5 22.5 230 230 2) 5 22 5 315 350 325 31 5 250 HT JJ JB JII VI.S JI EY 36 34 105 84 86 159 10 S 57 83 8 32 59 65 121 14.2 101 22 118 99 12 2 12 03 29 5 330 315 Average alue C FI DERLY SUBJECTS (WITH OBLITERATIVE ARTFRIAL DISEASE) R JO ЈА 25 0 21 5 210 MF 240 255 255 760 990 305 315 375 310 355 28 0 73 32 44 73 28 60 323 69 39 32 97 62 49 51 94 616 MG VIN OB AD 210 Aierage I alue ·63 ALTERATIONS IN BLOOD FLOW 9 neuroses +7 or in bringing about predispo ing periarthritis tively in myredema and in Graves Disease 7 In its fullblown appearance the symptom com It seems logical to assume that the va cular re plex which has also been described as houl sponses involved are reactise to the changes in der hand syndrome ( exhibits all manife ta metabol m 3 rather than to a specific vascular tions of neurovascular sympathetic irritation action of the thyroid hormone It is of interest pain discoloration limitation of motion mus that an inhibition of kin capillary develop cular atrophy and spotty osteoporosis (Su ment has been shown to be regularly demon deck s hone atrophy) strable in congenital myxedema Devel For many years the term va oneuro es opment of skin capillaries to normal adult ( angioneuroses ) has been used to denote forms in treated hypothyroid children has like anything from demon trable arterio pastic dis Wise heen observed S 5 orders touch vague concepts as 'capıllary 2 The Adrenal Medulla and the re Functional di turbances in Chromaffine System Catecholamines blood flow as far as they are measurable or (adrenaline noradrenaline and possibly at least clinically demon trable and traceable others) are in all probahility the substances to faulty innervation have been di cussed un which mediate va oconstriction at the place of der specific headings Our factual knowledge neurohumoral transmis ion in the res el wall of such disturbances in the minute circulation Their role in the specific form of hypertension is extremely limited and mo t writings on the due to phaeochromocytoma is unques ubject have been highly speculative Use of tioned 76 17 What etiologic significance of the term vasoneurosis angioneurosis any they have in es ential hypertension is un doe not appear justified known 8 DISTURBANCES IN THE 3 The Adrenal Cortex Peripheral blood ENDOCRINE SYSTEV flow to the extremities has never been shown The serretrons of endocrine gland are car to be directly inyolved in adrenocortical hyper ried by the blood throughout the body and may or hypofunction To even touch upon the in affect any organ or aystem The vascular sy tricate relationship of adrenocortical secretion tem seems to be under the influence of everal to essential hyperten ion and to shock is not of these hormones (Part I) Recognition of within the scope of this book the close relationship between endocrine hor The Gonads The search for influence mones and the autonomous nervous sys of gonadal secretions upon peripheral blood u on the one hand and the import flow has hardly advanced since the early ob ance of sympathetic pathways for vasomotion servanon that ovarian extract inhibits the vis on the other hand could hardly fail to draw the ual disappearance of kın capıllaries following attention of workers ju hoth the endocrine and the administration of adrenaline & Sporadıc the vascular fields of research Nevertheless report appeared in the literature on the u e our knowledge of specific pathologic conditions of gonadic steroids in occlusive disease of peri concerning one or more endocrine gland is pheral arteries Such trials were based on the very limited results of animal experiments 80 81 Like other 1 The Thyroid It is a well known ob intestgiators we have not been able to demon ervation 0 71 that the skin of hypothyroid strate that med vrable changes in peripheral ubjects tends to be cool and dry and that these blood flow in man are attributable to action of individuals are inclined to feel cold very ea ily gonadic steroids Connection of some disturb under environmental conditions generally con ances in peripheral circulation to the gonads dered comfortable the exact opposite applies has been su perted on the basis of sex distribu to patients with a hyperactive thyroid In the tion je the comparative rarity of obliterature older literature the terms hypocirculation arteriosclero is in non diabetic females hi her and hypercirculation have been used respec incidence of obliteratze thromboangutis in tem 9 ·62 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE . The di ease pic 1 the regulation of flow through the sascular bed to be invariably present in people who in the of the skin (Sce fig 3) ab ence of organic va cular disea e have at Surface temperature does not fall with the de tacks of sudden blanching of several fingers of crease in blood flow in the sympathectomized the whole hand either elicited by exposure to limb in response to body warming the result cold or by emotional upset or both This phe ing lack of correlation between changes in sur homenon has been de cribed as doits morts face temperature (which reflects blood flow in or as peripheral syncope the va cular bed of the skin) and total blood ture described by Raynaud as symmetrical flow to the limb (which may be taken to be gangrene 187 included this phenomenon is one predominantly representative of blood flow to of its features it is frequently called Ray the va cular bed in the mu cles) sugge is that nauds Phenomenon' Apparently it may oc there are different and eparate mechanisms cur superimposed upon occlu ne vascular di regulating vasomotor responses in these beds ease but a direct connection with the vascular Confirmatory evidence has been pre ented re dicea e has never been demon trated The ma cently by Edholm and his co workers jority of patients with occlusne peripheral ar Furthermore the fixation of surface tempera terial di case do not exhibit Raynauds Phe ture (kin blood flow) indicates that blood nomenon The cuspicion appears justified that flow to the kın is primarily under neural con the occurrence of Raynauds Phenomenon in trol while blood flow to the mu cles is influ patients who have occlu le va cular di ea ei enced to a much greater degree by other regu just incidental since it is not too rare in the latory mechanisms population at large Recent observations 37 sugge t the po si Bone atrophy due to vasospa m was de bility of influencing reflex vasomotor re scribed by Sudeck 9 Sudecks Atrophy 1 sponses in sympathectomized limbs toward characterized by spotty o teoporosis which i normalization by adrenergic blockade Tlus al o ob ersed in reflex dystrophy (houlder possibly implies that circulating catechol hand syndrome) amnes play a considerable role in the e re Vasospa tic disturbances have been de pon is Much further investigate work is re cribed as occupational di ea e in pneumatic quired to establish a possible linkage to the tool workers and planı ts and typists the cla sical findings of Cannon and lus co work la Ituo insolving milder forms The fingers or 397 concerning the sensitization of dener hands show di coloration and the patients re vated structures to adrenaline port a feeling of pins and needles or numb At the time of this writing much remains ness Much more rarely we have observed the unknown about the role of the autonomic nerv phenomenon in feet and tocs of some people ous sy tem in influencing peripheral blood after prolonged tanding in fast druung bu e flow The fact that purely psychic (emotional) or trucks (tran portation of soldiers ) Occlu timulı may have a visible and escn measurable sive di ca e following repeated occupational effect on vasomotion increases the difficulty in trauma has been ob eried 61 arriving at conclusions Reflex dystrophy of an extremity more fre The differentiation between vasoconstric quently the upper than the lower was origin tor and vasodilator disorders may be main ally described after injury or operation It tained at pre ent as a workable classification has since been seen not infrequently after myo for want of a better founded one It is wel! cardial infarction64 and occasionally in however to keep in mind that this clasification ca es of rheumatic heart di ea e It is of inter is based upon a working hypothesis that is not el that in cardiac patrents who exhibit this entirely supported by facts symptomatology the right upper extremity is Various equelae of a tendency to local pe in olsed almost as frequently as the left The ripheral vasoconstriction hase been described etiologic role of di use has not been clearly de A background of emotional disturbance seems termined but it is presumed that it is a factor ers ·ALTERATIONS NY BLOOD FLOW 65 ог bated question appears of relatively little bility of the blood per se is hardly a sufficient ignificance ince both are so clo ely con explanation since patients may have a pro nected ng The syndrome may be due to tuo longed prothrombin time without any extra types of anatomical anomaly muscular or ke Tacation Increa ed capillary fragility seems letal ” The muscle mot frequently shown to largely unrelated to the state of blood coagula have an anomalous course exerting pressure on bility nerve and blood ve els is the scalenus anticus Patients with polycythemia vera (primary less frequently the scalenus medius The skele polycythema) are reported to have an in tal anomaly re pon able for the syndrome is a crea ed tendency to thrombo 1 185 This does cervical rıb Alo costoclavicular compre ion not apply to patients with econdary polycy has been found to be responsible for the synı thema due to chronic pulmonary di ea e drome in some ca es *99 This type of neuro In 1937 lygaard and Brown described an vascular compre sion can be elicited by having entity they called essential thrombophilia This the patient force the shoulder backward and rare condition leads to multiple venous and downward The syndrome occurs most fre arterial thromboses 30 Increase in number and quently unilateralls only rarels bilaterally changes in physical properties of platelets ag Differentiation from brachial neuritis is ome well as increa e in globulin and fibrinogen con times not easy however deep in piration tent of the erum have been demon trated303 turning the head to the affected side or elevat in the e cases On the other hand there is a ing the arm may produce palpable diminution rare form of thrombocytopenic purpura304 de even disappearance of the homolateral scribed as thrombotic thrombocytopenic pur brachial and radial pul e "99 It has been pura where a reduced number of platelets 19 hown by Wrightand that abnormal position of associated with multiple thrombus formation in arms during leep may produce the syndrome mall ve sels It is actually difficult to decide Complicating thrombosis of the subclavian res whether both of the above di cu ed conditions els is a rare but, of course very erious oc should be cla sified as primarily vascular or hematologic Arthritic and other orthopedic deformities may cause local di turbances in blood flow SENSITIVITY REACTIONS The e rarely concern arterial supply fre Since the clasical de cription by Lewis of quently however they apply to senous drain the triple re-pon e in the minute blood ses els age and ometimes minute circulation through of the human kin to mechanical timulation localized pre ure even to the degree of super (dermographia) and to hi tamine it has been ficial (decubital) ulceration recognized that the wheal (as produced by his Secondary hypervascularization accompany tamine in tillation) is the basic lesion of most ing excessive apposition of bone may act like hypersensitivity reactions It has been known a large arteriovenous shunt with all its seque that the minute ves els in the mucous mem lae This occur in progres ed ca es of Osteitis branes may exhibit the same type of re pon e deformans (Pagets Disease) 197 lothing is known about the capıllary reaction in parenchymatous organs CHANGES IN THE COMPOSITIO The reaction may be een unaltered or OF THE BLOOD widely modified in tascular sensititaly reac Various blood dyscrasias are known to af tions to cold There are patients who develop a fect the permeability of the capıllaries and to giant everely atchy urtica upon immer non of cau e punctate or even larger extravasations their hand or feet in cold water involving ex Thrombocytopenia and various forms of leu actly the immer ed portion the e ame patents kemia may be mentioned here The mechan report general ensitivity to cold producing 1 ms at play are unknown Reduced coagula burning pain itching and swelling of the ex currence 301 ·64 PERII JERAL CIRCULATION IN HEALTII AND DISEASE SIS A1 91 males and higher incidence of Raynaud s dis the phenomenon of diminished blood upply ease in females Conclusite eudence however ill fluctuate and affect various extremities at 1 lacking It may well be that the recently Jarious times Vany years ago Sahl: described started investigation of the role gonadic ster what he called hypercirculation in ca es of ords play in the development of athero-clero anemia and hyperthyroidism basing his as might furnish clues in re pect to sex sumption of increa ed rate and selocity in pe linkage of peripheral va cular di ease ripheral flow on studies with the Gaertner tono 5 The Pancreas The obseration of a meter ? His assumption has been subsequently peculiar bright pink color of acra (cheeks confirmed by more reliable method of mea ur no e fingers toes) in diabetic patients was ing peripheral blood flow Rg It is of consider common in the pre insulin era 70 193 These pa able interest in this connection that in both tients regularly showed an abnormal dilatation anemia and hyperthyroidism failure has been of the capıllary segment connecting the arterial hown to occur in the presence of increa ed and venou limbs when the involved areas were cardiac output vened under the microscope 58 34 It is in That tonus of the large thoracic veins may tere ting to note that this can no longer be ob play a role in some of the mechanı ms involved erved in the in ulin treated case The mechan in cardiac failure has been widely di cu ed po I m of the phenomenon is unknown The role extremity veins may play in homeo 6 The Pituitary Putressin a pressor sub stasis of venous tone and pressure is unknown stance ascribed to posterior lobe secretion is but is currently under inve tigation by Val probably either secreted by intermediary lobe kins and his group substance wluch has grown into the posterior The role of minute ves els in experimental lohe 0 * or produced by neurosecretory cells shock has been studied thoroughly It has been in the hypothalamus and stored in the posterior hown on the capillary circulation in the mes pituitary lobe * It has a markedly constrict entery and omentum of the dog and in the rats ing effect upon minute blood vessels in everal mesoappendix that in the first (resersible) va cular hed 4* including the kinin stage of hemorrhagic shock the blood ve sel 70 At pre ent there are no data available exhibit construction and hyper en itivity to wuch would clearly indicate a direct effect adrenalin ) It has further been shown that upon peripheral blood flow in any of the ac during this tage a vasoexcitor material cepted clinical entities a cribed to pathologic (VEM) probably identical with renın changes in the pituitary erated In the later (irreversible) state of hock the blood vessels dilate and their re CHANGES I\GF\FRAL CIRCULATIO\ sponsiveness decrea es In this stage a vasode The relationship of va omotor responses in pres or material (VD) was found in the the extremities to the leart has been di cussed blood This supposedly active through its in Part I ferritin content 93 Markedly dimin hed left ventricular output AB\ORVALITIES OF THE (eg in tight mitral tenosis) leads to mark MUSCULO SUFLETAL SYSTEM edly diminı hed filling of the vascular system in the extremities with reactive constriction Scalenus anticus syndrome is a term ar This may lead to all the equelae of diminished phed to a symptom complex " cau ed by pres blood supply--including gangrene at the acra sure on the brachial nerse plexus and the sub —and the condition may be difficult to differ clavian ses el Such pressure leads to pain entrate from primary sa cular di ea e Evalu discoloration and changes in perspiration and ation of the case as a whole and a good history urface temperature It is not clear whether will facilitate the decision A ball vale throm the symptomatology is primarily due to nerie irritation or to vascular rasm the much de bus may cause a similar picture except that man is lib ·PATHOLOGIC ALTERATIONS IN BLOOD FLOW 67 ILIKY BY Chief roblem in connection with arterioscleroy Clin Vied 31 15 1933 38 STOOKEY PF FERRI Ch AD TARXLR H V Tecrotizing ulcers complicating ensire las J AVA 103 903 1931 23 DLFF GL AND VIC VILLAY GC Pathology of athero clerosi Am J Med 11 92 1951 21 LEARY T Fxperimental athero clerosi in the rabbit compared with human (coronary) atherosclero is Irch Path 17 453 1934 25 STEELE J MI Arterio clerosis (Lipid Vietabo Iusm) in Corodry s I roblems of Aging Biologi cal and Vedic al Afects Balumore alliams & Wilking 1952 39 SPIN AND KEEFER CS Renal and dermatologie complications of gonococcal in fections New England J Med 217 211 1937 40 SLALCHTER W H Symmetrical gangrene of malarial origin JAV 4 86 1607 19 6 #1 GOLLEY BA. The role of mitral tenosis and of post rheumatic pulmonary fibrosis in the evolution of chronic rheumatic heart di case Am J Ved bc 196 11 1938 26 D410 OY J D Diet and lipotropic agents in arteriosclero $ Am J Med 11 736 1931 27 KEYS A Iluman athero clero is and the diet Circulation 5 115 1952 2 RITCHIE W T Acute rheumatic carditis Lan cet 1 581939 13 los ALBERTINI 4 Pathogenesis of Aschoff nodule Schweiz Ved Wchn chr 83 77 1933 28 GUBVER R AND UNCERLEIDER ITE Arterio sclero is a statement of the problem Am J Ved 6 60 1919 41 KAR YER HT AND BAYLISS F Coronary ar terie in Theumatic fever Ant Heart J 9 551934 29 Russ EV EDER HA AND BARR DP Protein lipid relation hop in human pla ma I In normal ind sidual Am J Med 1 468 1951 33 AD 1315 J # JR Intracellular bacıllı in intes final and mesenteric lestons of typhoid fever Am J Path 15 561 1939 30 JOVES II B GOFMAN JY. LINDGREN FT. LYON TP CRAITAN D V STRISOMER B AND NICHOLS AI Lipoproteins in atherosclerosis Am J Med 11 358 1951 46 LEARVONTR GE Gangrene of the lower cx tremities complicating scarlet ferer Canad MAJ 15 69 1995 31 BARR DP Ru« F M AND EDER HA Pro tein lipid relation hips in human pla ma II In atherosclero is and related con i tions Am J Med 11 490 1951 47 Boyd W The Pathology of Internal Diseases Philadelphia Lea & Febiger 1944 3? DUCLID I B Thrombosis as a factor in the pathog ne 19 of coronary atheros leron J Path & Bact 58 %07 1916 48 Wood P Diea es of the Heart and Circula tion London Eyre & Spotti woodes 1950 19 PERRY TT 410 ALLEY E Va cular clinics VII Acute arterial thrombosis following contusion Proc Staff Meet Mayo Clin 18 19 1913 33 DUCLID J B Thrombo is as fa tor in pathogene in aortic arterios lero is J Path & Bact 60 57 1918 50 FLETCHER E AD R41CY RM War Wounds and Injuries Balumore Williams & Wilkins 1910 31 DuctID J B The etiology of atherosclerosis The Practition r los 211 1935 35 KRAMER DI Report of a case of pontane gangrene simulating purpura due to acute thromboarteritis. In Manual of Pe ripheral Vascular Disorders, Philadelphia Blakı ton 1910 51 ANDERSON W Contu ion of arteries Brit J Surg 7 93 1919 OU 36 WOLBACH S B., TODD I LAND PALFREY F The Etiology and Pathology of Typhu Cambridge Harvard Un Pres 19.9 59 LE FEVRE, F A. Arterial thrombo is following tmple contu ion Am Heart J 1 111 1939 53 SYMMERS #STC Thrombotic microangiopathic haemolytic anaemia (thrombotic microan opathy) Brit I J 2 897 195? 51 SYMMERS ST CAND BARROW CLIFF DF Platelets thrombo is yndrome J Path & Bact 63 552 1951 37 BAILLY L 4 Occlu ion of arteries of limb in d phtheria Internat Clin 157 1970 ·66 PERIPHERAL CIRCULATION IV IIEALTH AND DISEASE 101 po ed parts Gangrene of fingers and tocs has in animals may produce vascular changes been described as occurring with hemoglobin closely resembling some of those found in hu uris in syphilite patients upon exposure to man pathology 306 37 cold in some nonsyphilitic subjects exposure It is known that sensitivity angulis may to cold has been found to produce hemag so closely resemble primary polyarteritis no glutination accompanied by peripheral gan do all that workers in the ficld have found it grene Cryoglobulins have been found in the necessary to painstakınly c tablish the differ blood of such patients but al o in patients with ential diagnosis Recenth di ease pictures Raynaud s disease 30 have been described following the prolonged It is hardly within the scope of this book to use of the hypotensic agent Ily drazınophthal describe the sensitivity reactions to various azine that are indi tingur hable from rheuma drugs although some of them might hell be toid arthritis in some instances from dis cm primarily vascular Experimental work has inated lupus crythemato us in others 304 been plentiful to show that sensitivity reactions References --Part II 1 BAEUR C The significance of the eml olic glo merular le Tons of subacute streptococcus en docarditie Arch Int Med 27 62 1991 2 BRINK ) RASD SWU W) Subacute ) BC terial endocarditis clinical pathological study of 37 ca es Im lleart ) 14 362 1937 3 INDRLS DE W Peripheral arterial embo Il m with particular reference to esaluation of conservative trea ent Arch Surg 60 511 1950 11 KEY E Fml olectomy on ve sple of extremities Brit J Surg 24 350 1036 12 LENS T Pain as early symptom of arterial em oli m and its cait ation Clin Sc 53 1936 13 LINTON RR Acute peripheral arterial orclu sion and its treatment New England J Ved 210 871 1937 14 MADDEY J L. Technic for aortic embolectomy Surg Gynec & Obst 93 167 1991 15 LUND CC The treatment of eml oli m of the greater arteries Inn Surg 106 880 1937 16 MYSTRO3 G I ectures on Embolt m and other Surgical Suljects Baltimore William & Wil kın 1936 4 ATLAS LN Management of acute embolic oc clusion of arteries to extremities Surg Gynec & Ol1936 1917 5 BOYD AVI RATCLIFF A M JEPSON RI AND JAMES GW 11 Intermittent claudica tion J Bone & Joint Surg 31 3,5 1919 6 CATUSITOLE BN AND JEPSOY RP An eval uation of certain a odilator drugs ly a lipat flow technique Circulation 9 108 1051 7 CREFITII DL Irterial embolim Ian et 2 1339 1938 8 HALMONIC II Peri heral arterial emi olism tudy of 330 un elected ca es of emboli mol extremities Ingiology 1 20 1950 9 HOLDEND Acute Peripheral Arterial Oc elu on Springfield Thomas 1932 10 JEFFERSON G Successful ca e of enbolectomy with review of literature Bot M J 2985 1923 1. 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Arch Path 17 453 1931 35 STEELE J 1 Arterio clerosis (Lipid Vetabo- Jism) in Corodry s l roblems of Aging Biologi cal and Vedical & pect Baltimore Walliams & Wilkins 1952 39 SPINK AND KEEFER CS Renal and dermatologic complications of gonococcal in fections New England J Med 217 911 1937 40 SLALGHTER WH Symmetrical gangrene of malarial origin JAMA 86 1607 1996 41 COLLEY BA The role of nutral tenosis and of po t rheumatic pulmonary fib o 19 in the evolution of chronic rheumatic heart di case Am J Med Sc 196 11 1938 26 DAVIDSON JD Diet and lopotropic agents in arteriosclero is Am J Med 11 736 1951 27 KEYS A Human atherosclero us and the diet Circulation 5 115 1952 47 RITCHIE W T Acute rheumatic carditis Lan cet II 58 1939 43 los ALBERTINI A Pathogenesis of Aschof nodule Schweiz Ved Wchnschr 83 772 1933 28 CUBNER RAND U\CERLEIDER I E Arterio sclero is a statement of the problem Am J Med 6 60 1919 41 KARSVER IT AND BAYLISS F Coronary ar terie Theumatic fever Am Heart J 9 557 1934 in 79 Russ FM EDLA A AND BARR DP I rotein lipıd relation hips in human plasma I In normal individuals Am J Med 11 468 1951 45 ADAM J # JR Intracellular bacıllı in intes tinal and me enteric lesion of typhoid fever Am J Path 15 561 1939 30 Joves II B., COFMAY J LINDGREY FT Lyox TP GRAHAM DV STRISOMIER B AND NICHOLS AV Lipoprofens in ath to sclero: Am J Med 11 358 1951 46 LEARIONTH GE Gangrene of the lower ex tremities complicating scarlet fever Canad MAJ IS 69 1925 31 BARA DI Russ EM AND EDER HA Pro tein lipid relaton hip in human pla ma II In athero lero is and related conditions Am J \1 40 1951 47 Boyd W The Pathology of Internal Diseases Philadelphia Lea & Febrer 1944 37 DUCLID J B Thrombo is a a factor in the pathogene 19 of coronary athe osclerowi J 1 all & Bact 58 207 1946 48 Wood P Di eases of the Heart and Circula tion London Eyre & Spotti noodes 1950 19 L'ERRY TTAD ALLEN EV Vascular clinics XVII Acute arterial th ombo is following contusion, Proc Staff Meet Mayo Clin 18 19 1913 50 FLETCHER EAND RAVEN RW War Wounde and Injunes Baltimore Walhams & Wilkins 19:10 33 DUCUD J B Thrombo 1$ as fact r in patho Lenesis in ao ti arteriosclerosis J Path & Bact 60 57 1918 31 DUCUID J B The etiology of atherosclerosis The Practitioner 175 11 1955 35 KRAMER DW Peport of a ca e of pontane ou gangrene mulating fu pura due to acute thromboarteritis In Manual of Pe ripheral Vascular Disorders Philadelphia Blakı ton 1910 51 ANDERSON W Contusion of arteries Brit J Surg 7 93 1919 57 LE FEYRE FA Arterial thrombosis following simple contu lon Am Heart J 17 111 1939 36 WOLBACIE SB TODD I LAND PALFREY F 'Th Etrology and l'athology of Typhus Camb dg Harvard Uni Pre 192. 53 SYM VERS # ST C Thrombotic microangio. pathic haemolytic anaemia (th ombotic micro angiopathy) Brit J 2 897 195? 37 BAILLY L. 4 Occlu son of arteries of ml in diphtheria Internat Clin ? 157 1990 51 SYERS W ST CAND BARROWLIFF DF Platelets thrombosis syndrome J Path & Bact. 63 557 1951 ·68 PERIPIFRAL CIRCULATIOV IN HIFALTII AND DISEASE 55 SEACHAN CC ET AL Thrombotic thrombo cytopenic purpura diseminated do ea e al arterioles Blood 6 06 1951 56 REVILL. 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CALTABIANO S AND VALLERIN C Effect of ſoll culta on experimental athero sclerosis Rass di 6 10pat. clin e terap 94 355 1937 ·74 PERIPHER IL CIRCULATION IV IIEALTH AND DISEASE 203 CANNOY BAND RATPORT D Studies on conditions of activity in endocrine glanda de nervated heart in relation to adrenal secretion Am J Physiol 58 08 1921 210 BARCROFT HAND WALKER AJ Return in tone of Blood vessels of the upper limb after sympathectomy Lancet 256 1035 1919 211 BARCROFT HI AND LYNN RB Circulatory changes in the foot after lumbor >mpathec tomy Lancet 258 1]05 1951 212 COETZ RY Rate and control of blood flow through the skin of the lower extremities Am Heart S 31 116 1916 Some 44 25+ Canno # B., NEWTON I F., BRUCIT E. A.. MENKIN V AND MOORE RM pects of the physiology of animals surviving complete occlusion of sympathetic nerve im pulses Am J Physiol 89 81 1929 255 FREEMAN ME AND ROSENBLUECII A Reflex stimulation and inhalition of vasodilators in sympathectomized animals Am J Physiol 98 151 1931 256 CANNOY #BAND Rose ALUETH A Sen tization of denervated structures Am J Pays Jol 116 25 1936 !תו -13 RTYZMETAL ME AND WILSON C Nature of the peripheral re i tance in arterial hypertension with special reference to the vasomotor sys tem J Clin lmest 15 63 1956 2+1 GRANT RT AND HOLLING HE Vascular re ponses of the human limb to body warm evidence for sympathetic tasodilator nerves in the normal human subject Clin Sc 3 273 1938 245 WILKINS RW AND FIcIv4 L 1 Blood flow to the forearm and calf 1 asomotor Teat tions and the role of the sympathetic nervous ystem Bull Johns Hopkins Hop 68 4'5 1941 216 DUFF RS AND SWAN HJC Further ob ervations on the effect of adrenalin on blood flow through human keletal muscle J Phys Jol 11 41 1951 217 BARCROFT X AND SWAN HJC Sympathetic control of human blood ve sels London Arnold 1953 218 AJMAD A Paradoxical responses to changes in local temperature in the hands of a recently ympathectomized hyperhidrotic ubject Clin Sc 13 351 1951 j 957 FREEVAN NE SMIJWICK RILAND WIUTE JC Adrenal secretion in man The reac tions of the I lood ve els of the human er tremity ensitized by sympathectomy to od renalm and to adrenal secretion resulung from ansulin hypoglycemia Am Physiol 107 529 1931 258 MUELLER O Die Kapıllaren der menschlichen koerperoberflaeche in gesunden und kranken Tagen Stuttgart Enhe 1992 259 SUDECK P Ueber die akute (reflektori che) Knochenatrophie nach Fntzuendungen und Verletzungen an den Extremitaelen und ihre klinischen Frscheinungen Fortschr auf d Cebiete d Roentgenstr 5 277 1902 760 HABILTOY A Effect of the air hantmer oni the hands of stonecutters Pub Health Rer 33 488 1918 261 BARKER NW AND HINES E A JA Arterial occlusion in the hands and fingers Asociated ith repeated occupational trauma Proc Staff Meet Mayo Clin 19 315 1911 262 DE TAKAIS CEZA Reflex dystrophy of the er trenities Arch Surg 31 939 1937 219 I ODDIE IC SHEPERD J T AND WHELAN R F Vasocon trictor and vasodilator nerses to the human forearm Presented at the 90th International Physiological Congress Brus sels Belgium Avg 1 1956 250 EDITOLN OG Fox RII AND MACPHERSON RA The va omotor control of the cu taneous circulation of the forearm Presented at the 20th International Physiological Con gress Brussels Belgium Aug 1 1956 251 EDHOLM OG Fox RTI AND MACPHERSON R. The effect of body heating on the forearm blood flow Presented at the 20th In ternational Phy hological Congress Brussel Belgrunt Aug I 1956 252 REDISCH W TANGCO FF AND STEELE JA Unpublished data 63 ASNEY J AI The syndrome of painful disabil ity of the shoulder and hand compliating coronary oclusion im Heart J 271 1931 963 ERNSTENE A C. AND KIVELL, J Pain in the shoulder as a sequel in myocardial infarction Arch Int Nicd 66 800 1910 P, EIDEKEN J AND WOLFERTH CC P'ersistent pain in the shoulder region following myo cardial infarction Am J 11 Sc 191 201 1936 ·Part III Physiologic Responses to Disturbances in Blood Flow GIAP 1 DEVELOPMENT OF SECONDARY (COL. LATERAL) CIRCULATIOY CHAP 2 RESTORATION OF PROVARI CIRCLLA TIOV Sasturbances 150 holood Flowers, the ob sions 6 pred of POSTANEOUS vasomotor responses to local tremity sessels have been observed following travma and operations as well as in te served to be favorable or unfavorable in the ponse to thrombotic 5 and embolic occlu ense of repair and restoration It may be stated that in general vasoconstrictor responses are It is conceivable that a va cular bed de unfavorable vasodilator respon es favorable part of its blood supply might be It is of considerable interest that the same aided by a vasocon trictor response in another timulus may produce either vasoconstriction vascular bed causing shunting of blood to the or va odilation of the minute blood ve sels place of need There is no concluire esidence re pective to the smaller or greater intensity available at pre ent to support this otherwise with which it is applied A light stroke upon rea onable a sumption the human skin with a blunt or pointed instru On the other hand va odilator responses ment produces a white reaction due to vaso at the place of need have been observed both constriction wa an aron reflex Jf the same experimentally and clinically and the devel type of stimulus is applied repeatedly or with opment of so called collateral circulation has greater intensity the triple response been proven morphologically odilation is elicited This can be een as a Quiring has pointed out that there eems red reaction in the line of stroke accompa to be a certain degree of freedom in the final nied by vasoconstriction on both sides of the distribution of blood se els as expres ed in line and the development of a capıllary flare the many anomalies and variations of vas followed by wheal formation (pa sage of serum cular patterns in the body It 15 conceivable from the dilated vessels into the tissues) along that the physico chemical forces at play lead the line of red reaction 1 to the formation or further development of Va ocon trictor re ponses in the larger er vascular channel where needed 8 13 le vas Chapter 1 Development of Secondary (Collateral) Circulation The principal arterial channels to the ex are gis en off which not only supply the tissues tremities have been reviewed in Part I These in the immediate and farther neighborhood of vessels are primarily responsible for the blood the parent trunk but which in turn give off supply of the limbs and are therefore referred smaller twigs that meet or anastomose with lo as primary principal or main stem arteries similar twigs from branches arising at some Along their entire course howeser branches other point from the ame or another parent 77 ·76 PERIPHERAL CIRCULATION I HEALTH AND DISEASE 296 Dovald J MAND MORTON B F The scalenus anticus syndrome with and without cervical nb 111 709 1910 297 NAFFZICER II CAND CRAY AT Neuritis of the brachial plexus mechanical in origin the scalenus syndrome Surg Gynec & Obst 67 727 1938 298 FALCONER MAAND WEDELL, C Costocla vicular compre ion of subclavian artery and sein relation to scalenus anticus syndrome Lancet 2 161 1951 299 ADSON AW AND COFFEY J R Cervical rib a method of anterior approach for relief of symptoms by division of scalenus anticus Ann Surg 85 839 1927 300 Wricht IS The neprovascular syndrome pro duced by hyperabduction of the arms the im mediate changes produced in 150 normal con trols and the effects on some persons of pro Jonged hyperabduction of the arms as in leeping and in certain occupations Heart J 29 I 1945 301 ADSON AW AND ALLEY EV Thrombo is of arteries of the right upper ettremity re ult ing from anomalous first rib Proc Staff Meet., May > Clin 13 63. 1938 302 NYCAARD KL AND BROWY CE E sential thrombophilia Report of 5 cases Arch Int. Nied 50 82 1937 303 MONTO RW GRIEST W D AND Szitacer D E Essential thrombophilia Arch Int Med 90 63 1952 301 ORBISON JL. Alorphology of thrombotic thrombocytopenic purpura with demonstration of aneury m Am J Pathol 28 129 1952 305 BARR DP READER OG AND WHEELER C. HI Cryoglobulenemia Report of 2 cases with dis cussion of clinical manifestations incidence and significance Ann Int Med 32 6 1950 *06 Rich & RAND GRECORY JE Experimental demon tration that pertarteritis nodosa 15 manifestation of hyper ensitivity Bull Johns Hopkins Hosp 72 65 1913 307 RICH AR AND CRECORY JE Experimental evidence that lesions with basic characteristics of rheumatic carditis can result from anaphy lactic hypersensitivity Bull Johns Hopkins ios 13 234 913 308 Talbott VII AND VALORES FERRANDIS R Collagen Diseases New York Grune & Strat Am ton 1956 ·SECONDARY (COLLATERAL) CIRCULATIOY 79 A B 11 11 11 I II A B А III IV Fic 4 SCHEMATIC DRAWINGS DEPICTING THE DEVELOPMENT OF COLLATERAL CHACULATION IN ARTERIAL OCCLUSION I Normal 1 essel (A) Mote the functioning side channel (B) an the nonfunctioni &preformed hannel (C) 11 Incomplete occlu on The functioning side channel proximally to the o clu son has widened andle ome to tuous by elongation III Pogressed or lusion The nonfunctioning prelormed channel prouimally to the occlusion ha le ome a lun 1 ning collateral 1 Compi te o fusion Both collaterals have deseloped connecting I ranches to the main ses sel di tally to the ocelu on ·78 PERIPIIERAL CIRCULATION IN HEALTH AND DISEASE trunk Such anastomoses then form archlike referred to his book vascular channels conveying blood in the Although the anatomic development of col same general direction as the main artery, com lateral circulation has been studied thoroughly pared to which they are much smaller in cal in various organs the mechanisms at play are ber These channels then are collateral sec till not fully under tood Physical force ondary or accessory to the parent vessels from like differences in intravascular pressure in the which they are anatomically and physiologi occluded sessel as compared to that in the cally distinguished The primary vessels are collateral channels have been considered of larger in size and direct in their course and prime importance The accumulation of car they convey the greater portion of the vascular bon dioxidet in the area supplied by the oc supply to the part while the secondary or col cluded ves el has also been used as an explana lateral vessels are smaller more circuitous and tion and nervous mechanisms set into motion carry only a comparatively small portion of by the occurrence of the occlusion have been the blood Histologically these two groups of demonstrated to play a role 15 Experimentally es els are exactly alıke sympathetic denervation appears to influence It is understandable that obstruction at any favorably the opening of collateral channels point in the principal arterial trunk is followed induced by an artificially produced arteriore hy a compensatory response in the channels nous fistula 18 17 Mulvhill and Harvey 10 re bridging the occluded portion directed at tak sicwed some of the hypotheses that have been ing over such function as can no longer be postulated to explain the production of col performed by the obstructed sessel Vheneser lateral circulation and they confirmed on the the primary vessel is impaired in its entirely basis of their experiments the operation of a or almost so (as it happens in some forms of vasomotor component According to Spalte generalized arterial di ease) the collateral holz 18 the following factors are the main channels alone assume the responsıbıhty of determinants the extent arrangement and supplying the part in that event the collateral condition of the ses els in a given vascular vessel ceases to be an accessory and indeed bed the status of the general circulation the becomes the primary channel while the origi general condition of the body the time ae nal principal vessel may even be converted quence of the occlusion and the animal species into a functionless cord Briefly an adequate collateral circulation is The adequacy of the circulation following likely to develop of the occlusion occurs in an obstruction of the principal vessel thus de area with a rich blood supply of the anastomo pends upon the ability of the collateral vessels tic vessels in the area arise from several vessels to enlarge sufficiently to carry over the blood and if the walls of the collateral vessels are not which would normally have coursed through diseased or otherwise incapable of dilatation the occluded channel Quiring? quoting Spal Deficiencies in cardiac function hypoten ne teholz expressed this mathematically If the states dimunition of blood volume below criti sum of the aquares of the cross sections of the cal levels and disturbances in composition or ana tomosing ves els equals or is larger than viscosity of the blood adversely affect the de that of the square of the occluded artery the selopment of collateral blood Now A good ana tomosis is adequate general condition of health in the individual The pre existing anastomosing vessels which and intactness of the venous system are es en normally serve as accessory or collateral chan tial in sudden occlusions the number and nels are enumerated and well illustrated in xtent of the pre exi ling anastomotic channel standard texts of anatomy Quiring gives an are of primary importance while in gradual excellent and detailed discussion on collateral occlusions the condition and nature of the walls of these ressels are decisiye Vascular vessels the reader interested in the subject is ·SECOVDARY (COLI ITERAL) CIRCULATION 81 ure) - ? Such ituations may frequently be we and more efficient collateral network is obsened in the loner extremities of people af till a matter of peculation flicted with obliterate arterio clero is One In summary anatomcall, the exı tence of is tempted to talk about diramı hed arlenal three types of econdanks deseloped channel re erle or local circulatory re erre making might be po tulated i Channels bypa. ing these terms corre pond to tho e ed in dis the primary route, pre er ting and in active cu ing cardiac work performance Le even prior to the occlu ion of the primary In the event of sudden complete occlusion channel now being widened and lengthened the blood available from pre exi ting collateral (by meandering) and thus made niore capable Te el may be grossly inadequate to meet the of carrying the additional load the e are col needs of the part the circumstances are of lateral channel in the strict ense of the word cour e rather unfavorable for the further de 2 Preformed (potential) channel part of the velopment of the eles els Moreover there is arteriolar and capillary bed which are not u ed hardly any time for the formation of new vas permanently but are called upon when the cular channels It is indeed amazıng that, de neces ily ari es 3 Rewly formed channel pite this condition a part not infrequently The recently reported findings sith the elec recovers from what cemed to be complete tron micro cope * revealing interesting struc embolic arterial occlu on This happens more tural details of the capillary wall may well often in the upper than in the lower limbs point the way to a better under landing of ses Thether this is due to the difference in vaso el formation under normal and pathologic motor tone or to the pre ence of a more exten conditions Chapter 2 Restoration of Primary Circulation It would appear logical to talk about pon rum from the urrounding wall penetrate the taneous efforts of the organi m to restore plug new capillaries grow in from the free function to the primary impaired blood res end of the thrombu which has been covered els proper before di cu sing the various as with endothelium and blind channels (rifts) cular re pon es leading to the development of within the plug become endothelialized and de collateral circulation The fact is hones er velop into nen blood channel 30 2 Through that the body s means of re toring primary cir relaxation of the se el all around a recent culation in an occluded ves el are few and embolus whereby occlu son recurs more dis low in achon and in the overwhelming ma tally as the embolus reaches narroner egment jonity of in tances are widely overshadowed by of the le el If the embolus finally lodges in an the manifestations of collateral circulation area with ample ana tomo ing circulation its There are only two known ways in which effects may be insignificant, as pointed out be spontaneous restoration of pa age through fore 31 Recanalization may logically be er an occluded a cular channel can occur 1 By pected to occur more readily in large arteries canalization of an organized thrombu hich than in mall caliber veel ince it is prob occurs only in larger le els and u ually after ably dependent upon the vis a tergo of the on a lapse of many months or years There are ruhing blood and the number of sasa va o three forces at work in this proces rum prevent 3 38 Sas: 120 ·80 PFRIPJIER AL CIRCULATION IN HEALTH AND DISEASF may be dif 3 4 No ex responses differ quantitatively and/or qualı original channel may then persi t only as a latively among various species small contributory branch to the newly formed With these considerations in mind it may vascular set up An example of this condition be mentioned parenthetically that while the is the schiadic artery which is originally the conditions for the development of collateral main supply of the lower limb aubsequently circulation in the heart muscle19 this role is taken over by the femoral artery ferent from tho e in the extremities there are and its branches the ischiadic artery only striking analogies in the coure of events fol supplies contributory elements to the deep lowing arterial occlusion femoral and anterior tibial branches The discussion has been limited so far to Third the reversion and rea sumption of the opening or enlarging of pre existing col embryonic functions by organs and tissues lateral channels An even less understood phe which have long lost those capabilities un nomenon is the apparent development of en der conditions of need and stress is a well tirely new vascular channels in respon e to oc known chnical phenomenon The resumption clusion of primary ra cular routes of erythropoiesis by the hver and the spleen in planation is offered However certain embry cases of marked and severe anemia are illus ologic phenomena may make uch new for trations of this phenomenon The mechanisms mations not entirely surprising or unexpected insolved are unknown and one can only specu First it may be recalled that the first vas late John Hunter s empirical statement that cular channels in ontogenetir development blood goes where it is needed may indeed ari e from mesenchymal cells and are capil be altered to blood is sent here it is needed lary in nature and from this diffu e capıllary Thus the orcurrence of obstruction in a las bed by confluence and fusion of smaller ves cular channel creates an emergency locally els and with further differentiations the with an urgent need for blood in the area It larger va cular channels are formed The ul is conceivable that under these circumstances timate size of the vessel produced is propor the me enchy mal cells in the area revert to tionate to the amount of blood the vessel would embryonic angiobla tic activity forming new be called upon to consey in the fully developed capillaries which in turn by fusion con organism As the organism deselops and fluence and further differentiation, may form grows two or more blood supply routes appear larger vascular channels to form in an area ome of the e remain un Physiologic respon es to curtailment of cir developed or are diverted to other areas or culation to a part seem to be directed mostly organs toward the development of what has been Second the normal obliteration of fully termed collateral circulation In chronic dis developed vascular channels during embryonic ea e with slowly progre sing vascular ocelu and po tnatal life is equally difficult to ex sion restorative efforts of the organism along plain Some of these ves els are closed com the e lines may be so successful as to pre ent pletely and transformed into solid connective us with parts in which no evidence of open tissue cords presumably because they have primary channels can be detected but which outlısed their u efulne The Ductus ar eem to have a perfectly ufficient blood sup teriosus Botallı is an example of this phe ply by means of secondary developed chan nomenon In other in tance a fully deseloped nels it should be noted however that while Sessel which originally forms the main vascu circulation to such parts may be sufficient at lar supply to a part omehow undergoes re ret or even with slight exerci e it is u ually gressile changes or is arrested in its further not capable of coping with suddenly increased gile way demand des elopment to to sub equently uch as are called for by heai, er formed channels which then become the prin ercise external injury or when circulation in cipal blood supply route to the same part The general is interfered with leg in heart fail ·PHYSIOLOGIC RESPONSES IV BLOOD FLOW 83 31 ANDERSOY A D Vo by 1953 Pathology St Lout 3 Boyd Pathology of Internal Di ea es Phila delphia Lea & Febiger 1935 33 WOODRUFF CE Studies on the vasa vasorum Am J Pathol 2 567 1996 7 STEAD E. 4 JR WARREN J AND BRAYYOY FS Cardiac output in conge the heart failure analy is of reasons for lack of close correlation beinten ymptoms of heart fail ure an resting cardiac output Am Heart J 39 599 1918 8 STEAD E 1., JR Role of cardiac output in mechanı m of conge tive heart failure Am J Ved. 6 937 1919 mg KSCII B The contribution of electron micro scopy to the phytology and pathology of cir culation Present d at the 20th International Phy vological Conores Bru spl August 2 1956 30 KALFMANN Pathology for Students and Practitioners Philadelphia Blakıston 1998 31 LERICHE R AND FROEBLICH F Recherches experimentales ur l origine des arterites ob laterante Ann d anat Path 13 1039 1936 3) LERICIE R De la re ection etc le yndrome de l obliteration termino aortique par arterite Pre e Ved 43 601 1910 36 LERICHET Ollteration de laorte etc Mem d 1 Acad de chirurgie 66 691 1910 ·82 PERIPHFRI CIRCULATION ITEALTH AND DISEASE Refei ences - Part III 16 DETERLIYCRA Esser IE AND WAUCH Arterso-yenous fistula experimental study of sympathetic nervous sy tem on de velopment of collateral circulation Surg Gynec & OL 84 629 1917 17 IIALSTED SA striking elevation of the tem perature of the hand and forearm following the excision of a subclavian aneury m and ligations of the subclavan and axillary ar letjes Bull Johns Hopkins Hop 31 219 1920 18 SPALTEHOLZ # Handatlas u Lehrbuch der Anatomie des Venschen Revi ed by R Span ner Am terdam Scheltema & Ilolkema 1933 I LEWIS T The Blood Ves els of the Human Skin and Their Responses London Shaw 3927 2 KUETTNER II AND BARUCH M Der trat matische segmenta re Gefaes krampf Best z Mlin Chirurgie 1'0 1 1920 3 MONTGOMERY A HLARO RELATO 3 Trau matic egmentary arterial spasm JAVI 105 1741 1935 4 DE TAXATS C The use of papaverin in acute arterial occlusions JAVA 100 1003 1936 5 LLETH 11 C Thrombosis of the abdominal aorta report of four ca es howing the vari ability of symptoms Ann Int Med 13 1167 1910 6 SEIFERT E Die Deutung des Schmerzes bei der arteriell n Embolie Deute h Lauts hur í Chirurgie "32 187 1931 7 QUIRING DP Collateral Circulation Phila delphia Lea & Felnger 1919 8 MOTNYAGEL, }} Veber Anpa ungen und Aus gleichungen bei pathologichen Zustaenden Die Ent tebung des collateralen Arer laule Zeitschr i Nin Med 15 47 1889 9 MULLD A AND HAREY SC Studie collateral circulation J Clin Invest 10 123 1931 10 VULKAILL DAANO HARVEY SC The mechanı m of the deselopment of collateral circulation New England J Med 01 103? 1931 12 hou Tz B Reestablishment of circulation in extremilies Arch Phys. Therapy 20 157 1939 19 SCHLESINGER MJ An injection plus dissec tion study of coronary artery occlusions and anastomo es Am Heart 3 15 528 1938 "O BLUMCANT HIL SCHLESINGER M ) AND DALIS D Studies on the relation of the clini cal manife tations of angina pectoris coronary thrombosis and myocardial infarction to the pathological finding Am Heart J 191 19-10 21 PRINZMETAL Y SIVAIN B BERC VAY HIC AND RELCER RE Studies on collateral circulation of normal human heart by coronary perfo ton with radioactie erythro y tes and glass here Arch In cardiol Merico 78 122 1948 22 BLUSCART } ZOLL, MP FREEDPERC AS AND GILICA DP Frperimental Trodus tron of intercoronary arterial anastomosrs an 1 their functional ignificance Circulation / 10 1950 23 CLARK ERASD CLARK E L. Mew formation af arterio venous aha tomoses in rabbits ear Am] Anat 55 107 1931 12. PATTEX BV Human Embryology Philadel tha Baki ton 918 13 RECKLIYUSHALDEX F D Handbuch der all gemeinen Pathologie des hrtı lauſes und der Ernahrung Stuttgart Enke 1883 1 LATSCHENBERGER J AD DEGHNA A. Bestrage zur Lehre von der reflektoris hen Erregung der Gefas mu kein Archid ges Physio 12 157 1816 15 KOLESVIKOW Die Wirkung der Desympa thi ierung on Arterien mn Alkohol nach Ra umor ky auf die Entwicklung von Kolla teralen Zeitschr í d ges Anst 89 405 1999 2 CLARX FR CLARK EL AND WILLIAMS RO Wicro copic ob ptration in living rab fit of new gronth of nenes and e tal l, hment of nene-controlled contractions of newly formed arterioles Am J Anat 5 17 1934 > FRIEDBERG Chi h Diseases of the heart Phila delphia Saunders 1950 26 Dorn, # Heart failure relation of symptoms and signs to its seierity and duration Ann Int Med 29 11 1918 ·PHYSIOLOGIC RESPONSES IN BLOOD FLOIY 83 Patholog St Loui 31 DEASUŃ W Mo by 1933 32 Boyd W Pathology of Internal Disea es Phila delphia Lea & Fehiger 1932 33 WOODRUFF CE Studies on the va a 12 orum Am J Pathol 2 567 1976 my 51640 E A JA HARREV I 110 RRAY OY E Cardiac output in conge lise heart failure analy is of rea ons for lack of clo e correlation bimeen symptom of heart fail ure andre ting cardiac output dni Ileart] 37 5° 1948 8 STED EI JA Role of cardiac output in me hani mn of conge live heart failure Am ) Ved 6 32 1919 9 KECH B The contribution of electron MK TO story to the phy iology and pathology of cir culation Presented at the 20th International Physiological Congre Brua se hugut 1956 30 haL E Pathology for Students and I'ractition rs Philadelphia Blaksston 19.9 31 LERSCIFE RAND FRIENLICH F Recherches erperimentales url origine des arterites of Fiterante inn d'anat Tath 13 1039 1936 35 LEACE! De la re ection etc le yndrome de l obliteration termino aortique par arterite Tre e Med 49 601 1910 36 IURE I Qlliteration de laoste esc Mem d I Acad de chirurgie 66 621 1940 ·Part IV Management and Therapy CHAP 1 RESTORATION OF OCCLLDED PRIMARY TRTERIAL CHANNELS Medical means Surgical means Medical means Deep enous channels Superficial venous channels Surgical nieans Deep venous channels Superficial venous channels CHAP 4 INFLUENCES ON THE MINUTE VESSELS Cuar 2 ENIIANCEMENT OF COLLATERAL AR TERIAL BLOOD SUPPLY Medical means Drugs affecting blu h areas fecting glomus areas affecting I lood flow to the extremities Surgical means Cuar 5 UNDERLYING CONDITIONS AND Cow PLICATIONS Generalized a cular di case Related extrava cular conditions Sequelae of disturlsances in periph eral blood flow Cuap 3 INPAINVEYT OF VEYOLS DRAIVACE HERAI EUTIC ATTEMPTS to correct disturb Tances sont pe pheral 15ood formed beds rected either at restoring the occluded pri mary channel or at enhancing the development of collateral circulation The approach may be by esther medical' or surgical means - The disturbances in peripheral blood flow repre Sent in most instances either manifestations of generalized vascular disease or complica tions of an underlying extravascular disorder In turn the disturbances in peripheral circu lation may lead to complıcalıng sequelae Chapter 1 Restoration of Occluded Primary Aiterial Channels MEDICAL MFANS actile vasodilation The simplest and most u e Complete occlu ion of an arterial channel ful physiologic procedure to reliese arterial may be entirely organic ter completely oc pasta therapeutically is the one devised by cluding thrombus) partially organic (eg ribbon Landis Hest application to the chest partially occluding thrombus and superim back and abdomen maintained for 50 to 60 posed secondary constriction of the sessel) or minutes reflexly lowers vasomotor tone in the extremitie entirely due to reversible local constriction counteracts any rayocon trictor (so called spasm) timulus at play and induces vasodilation Arterial construction (spasm) may he re Pharmacologic release of vasomotor tone and thus of arterial constriction 13 be t accom lieved by procedures and drugs capable of re ducing asomotor tone Some of these proce plished through the low intravenous injection dures are said to be also capable of producing of either diethyl amino thanol or such gang 81 ·OCCLUDED PRIMARY CHANNELS 85 fronic blocking agents as tetraethylsimonium The e cases in large measure success depends pentolinium or hexamethonium While the al upon the condition of the rest of the va cular cohol does not cause any agnificant changes in tree at the time of operation ie the likelihood arterial pressure the quaternary amines mas of the grafts taking without rethromboeing produce marked by potension especially of the Tanes imersely ysth the age of the patient and postural type which may be elicited for en the degree of imokement of the other parts of eral hours after administration of the drug by the arterial channel by the di ea e process letting the patient assume the erect position Alas the more disłał the past grafted the less When tetraethylammonium chloride 1 used likely is the attempt to ucceed Grafting or dramatic drop in resting pressure is less often thrombendarterectomy below the inguinal lig encountered but postural hypotension is ju? ament is seldom succes ful The best war of as marked as with the more potent penta and dealing with a primary channel which has hexamethonum There are no direct medical been occluded by an embolus is of course means proven to help restore flow through an embolectomy 67 It should be employed when arterial se sel that has been occluded organi eter feasible and as early as possible after em cally The question whether an scoagulants bolization As a rule sir to eight hours are may be helpful is slowing doun organization considered the latest for surgery to be per of an occluding arterial thrombus and thus formed Honeser instances of uccesful em ad in its recanalızalıon has stall not pas ed the bolectom after a lap e of a considerably fate of a fairly reasonable a cumption longer pessod of time hase been reported * For technical considerations the reader is referred SURGICAL MEANS to textbooks of surgery in the ca e of throm Localized ob truction due to thrombu form borc arterial occlusions interfering with blood atron of embol n may be managed succes flow to the lower extremitie the results of fully by surgical methods radical surgery --arterectomy with res el graft Thromberdarterectomy: the excision of ing So in some cases perhaps also with intimal thrombus with repair of the artery when suc stripping' 15.-are very encouraging proud cessful restotes an ob tructed primary 1ascu ing one is dealing with not too extensic a far channel and allows blood to recirculate thrombus in a large se seli o The test te through the same routes sults have been described in saddle thrombs of Arterial grafting attempts to se establish a the aorta (occlusions right above the byfurca vascular channel which has been rendered un 110% often called Lenche Syndrome ) Tech serviceable by obstruction The various ma ases are de cribed in the surgical literature tersals u ed for grafting have included pieces quoted 1 hole everal years ago arterial se ec of a fun artery of a cloth tube made of tron was at times considered an adjunct to inyon Nylon Orlon or Dacross Vascular simpathectomy 1 most surgeons by now graſtıng may accomplash this 3sm m ino ways hale abandoned sympathectomy as an adjunct either the obstructed part ss resected and re to removal of the thrombo ed arterial segment placed by the graft or it ss left in situ and lery interesting experimental as well as chini by pas ed bs the grall cal 38% estiguison has been and is belag car Various report of such reconstructive oper ried out concerning the type pre ervation auon jare heen quoted as succesful in 50 use and securing of grafts to bridge vascular 90% of cases and have listed maintenance of delects # For detail the reader is referred patency for 6 months or longer 11 20 80% of to the abundant surgical literature on the topic ·86 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE Chapter 2 Enhancement of Secondary (Collateral) Aitciial Blood Supply MFDICAL MEANS tion (therapeutic application of the Gibbon The therapeutic usefulness of such measures Lundis procedure) It is necessary to apply as are mentioned abovc is by no means re this procedure daily for a prolonged period stricted to their effects on the primary arterial of time b Carefully graded exerci e under channel Their main value lies in their ability supervision This is done according to a ſexi to aid in the activation of secondary (collat ble plan quantitation of daily increments are cral) channels This purpose of course, calls based on repeated clinical evaluation Both for repeated and prolonged employment of the measures are not only capable of increasing therapeutic measures available blood supply to the cxtremity but are capable Medical means to cnhance collateral circu also of improving the vasomotor respon cs lation are directed not only at lessening vaso in the limb 30 motor tone but even more important at fenc For patients incapable of walking graded ing off further vasoconstrictor impulses to the erercise may conveniently take the form of the rea The basic principles of a 'peripheral well known Buerger s Exercise 31 The c arc vascular routine which have been fairly gen done daily for about a half hour and the fol erally accepted are the best example for the lowing sequence is recommended The pa application of the abovc on a broad conserva tient lying on his back first places his feet on tive basis The following routine measures are a support that provides an elevation of about frequently utilized 25 cm (67 in) for one minute and flexes h15 toes and feet rhythmically following that he 1 Keep extremities dry and warm sits up at the edge of the bed and dangles 2 Avoid injuries If such occur report fus feet for one minute One minute of rest immediately to the doctor in the horizontal position completes the cycle 3 Use wide firm shoes allowing for as This should be repeated up to ten times ac many pairs of woolen socks as ner cording to the patient s general status and his cssary I( actions As a rule patients with occlusive 1 Do not smoke arterial disea e experience pain either on ele 5 Take three ounces of Scotch Bourbon vation alone or on elevation plus exercise (x or brandy cept for the time of exercise it is advisable to permit these patients dependenry of the affected It should be noted that an important point in limbs to about 5 10 cm below the horizontal such routine measures is to hield carefully for at least a few hours each day unless edema the afflicted part against injury of any kind formation prohibits this for patients whose That should be also understood to exclude the general status (chronic congestive heart fail ue of local heat and of all local physio ure severe chronic pulmonary failure exten therapeutic procedures & except body warm swe ulcerations debilitations etc ) excludes ing for reflex vasodilatation and graded er esen the u e of Buerger s erercises the Saun ! If used early enough for example ders vaso cillating bed whirh replaces the in young diabetics such routine is probably actre exerci e with rhythmically induced the best means to present situations necessitat changes of blood volume and hydrostatic pres ing more radical specific treatment to this sure conditions in the extremities may be u ed preventive routine two more measures hould be added a Heating of the body (and non Since the time that Landis and Gibbon pub affected extremities) to induce reflex vasodila li hed their intere ting idea of applying alter ercise 7 ·COLLATERAL BLOOD SUPPLY 87 nate suction and pressure to enhance circula ducing vasodilation in various va cular beds tion in the lower extremities? various physio have been developed The reports on their therapeutic apparatus have been marketed for pharmacologic qualities have stimulated se the freatment of occlusive peripheral arterial neved intere t in the possibilities of medicinal diese In general all the e apparatus use the treatment of hypertensne di ease as well as principle of alternating ischemia and hypere of peripheral va cular disease Several of these ma * the danger of further damaging the drugs are valuable in both conditions hypoxic tissues during the i chemia phase out It appears convenient to class drugs that af heighs the possible heneſit * from passne er fect extremsty blood flow according to theis erce and reactie hyperema mea urable physiologic actions in man This Since 1923 3 fever therapy especially in allons for a more detailed classification ac travenous typhord vaccine has been u ed i cording to pharmacologic chemistry within the various peripheral manifestations of vascular groups so e tablished The mechanism of ac dies e Fever therapy has also been used at non is the most difficult criterion to use in clas times to influence the cousae of occlussre pe sification for some drugs work through more ripheral arterial disease 3s This type of treat than one mechanism using more than one type ment was based on the rationale that the ye of pathusy and some of these mechanisms are pon e to pyrogens includes delayed and long fairly well described while others are largely lasting vide pread na odılanon after the chill unl.nown Thus we may differentiate three It seemas however that this phenomenon ap groups ples to u ceral organs (especially the kid 1 Drugs with a predominant effect on neys) rather than to the extremiues Thus its blush areas expressed in surface temperature » e has been revived for the treatment of hy changes pertension 17 but its value in obliteralne ar teriosclerosis and obliterature thromboanga 2 Drugs with a predominant effect on 212938 39 18 doubtful to say the least In end glomus areas expres ed a surface tempera orterstede of unknown etiology including tem ture changes poral arteritis evaluation is extremely dificult 3 Drugs with a predominant effect on because of the self limited course of the e con blood flow to the extremisties as measured by ditions Acute arterirdes for example are plethysmography and surface temperature mostly accompared by fever changes There has been an increasing tendency to try to increase collateral arterial blood supply Group 1 through the u e of various drugs usually des Ilustamine This has been described as a ignated as vasodilators The e drugs belong capillary vasodilator It is capable of pro 10 different chemical and pharmacologic ducmg Lewis triple respon e in the skin in groups their mode and places of action difier mm mal amounts 0025 mg of bace by vein accordinely When di cussing the v e and use produces dilatation in the blush areas without fulness of this variety of drugs grouping ac allecting the glomus areas Side effects---sub cording to more than one criterion appears sternal oppression shortnesy of breath burn ing of kin--are somewhat less marked when of the agents ued in the past some have the drug is gren intra arterially in doses of Peter been proven by physiologic methods to 3 mg in 500 cc of salıne at a tale of 3 drops trast any measurable influence upon blood per beat" Even so sede ellects are almost in How to the extremities among these are the anably sufficiently marked to enforce a tem various pancreatic and other tissue extracts porary slow down of rate of adminstration hypertonıc alıne and aminophylline There is a significant but short rved increase in terent vars mam drugs capable or in un blood flow to the extremity which returns neces ary ·88 PERIPHERAL CIRCULATIOY IN HEALTH AND DISFASE to resting values after a few minutes, effect by Soma Weiss and Robert I Wilkın 47 48 upon the blu h areas by far outlasts the in s lo showed the dependency of its vasomotise crease in blood flow effects on posture in their end effect upon the Nicolinic acid This is one of the oldest extremities the nitrites cannot be classed as peripheral vasodilators Orally as well as vasodilators because they either do not influ parenterally it causes marked dilatation in the ence blood flow at all or diminish it 49 blush areas with very marked tachyphylaxis Roniacol (3 pyridine methanol or Bpyri Group 3 dsl carbinol) This is the alcohol correspond Numerous drugs have been developed re ing to nicotinic acid to which in the body it cently on a more physiologically specific basis is slowly converted 41 Its pharmacologic action Most of these drugs evert their tasodilatıng is e sentially that of nicotinic acid but pro action either by interfering with circulating longed through the low release The dose is catecholamines (antiadrenergic or adrenolytic 300 600 mg duuded into four daily doses drugs) or by action, posibly, on the sao Its u efulness in regulatory disorders of the motor centers in the central nervous system minute circulabon (chronic trench foot and many of them are valuable in the treatment the like.. ) s better established than that in oc of arterial hypertension as well as arterial clusie vascular disease *3 45 disea e of the extremites Some of them exert Paparerine has enjoyed some reputation as their action by more than one mechanı m an agent capable of influencing cerebral circu a Drugs uith predominantly anuradrenergic lation. In the periphery intravenous as well action as intra arterial administration of doses from Dibenamine (A.N dibenzyl B chlorethyi 75 150 mg are followed by vasodulation in the amine) 50 1 This is the mother sub cance of blush areas shortness of breath chest pain adrenolytic (adrenergic blocking) agents in and coughing spells It can be administered paren terally only becau e of its fugh peroral toxi Group 2 city furthermore its hypotensive effect 15 $0 Ethyl alcohol taken orally is probably the marked and su tained that it is not of practi oldest and most widely u ed vasodilator In calu e in peripheral arterial disease Diben single large doses (100 cc) it affects the zyline (A phenory Isopropyl N benzyl ß chlor blu l areas irregularly (it may either cause ethyl amine hydrochloride) which can be u ed dilation or construction there) but invariably orally is clo el related 10 Dibenamine, but causes marked increase in glomus area tem is five to ten times more effecties and much perature Used intravenously in the form of less toxic 3 The dosage varies considerably diethylaminoethanol 11 m in 50 cc of from subject to subject in respect to the pro water) it produces marked increase in blood duction of adrenergic blockade and to tolera flow to the extremity Procaine which has bility. It ranges from 10 300 mg with an some va odrlator activity *5 metabolizes to aserage of 60 180 mg daily administered in paraminobenzoic acid and diethylaminoetha divided do es The side effects are essentially nol Paraminobenzoic acid has no vasodilator due to exce ne adrenergic blockade The qualities o that any such action of procaine drug us rather slowly metabolized evidence of must be attributed to the diethylaminoethanol adrenergh blockade may be present as long as 2 to 3 weeks after di continuation 1 component Nitroglycerine and sodium nitrate hale Ilidar 16 Ally1 o 7 dihydro 5H diben known sasodilator qualities 45 The peculiar in zarepine pho phate) 57 15 very similar in its fluence of codium nitrate on the peripheral cir action to Dibenzyline It al o hares essentially its indications side effects and contraindica culation has been elucidated to a great extent common use ·COLLATERAL BLOOD SUPPLY 89 trons It is gren preferably by mouth daily marked postural hypołension it is not recom doses of 50 250 mg mended for therapeutic ue in occlususe pe Ben odiorane an adrenolytic agent has ripheral arterial disea e It also has been dem been u ed for the detection of pheochromocy onstrated to show decrea e in blood flow to the tomas It has not been used in peripheral as sympathectomized extremity GG It may how cular du ease becau e of its marked hypoten ever le ved in the diagnosis and evaluation site action and the potential dangers from it of arterial spasm Regiune (2 N ptoly m oxyphenyl ami flexameshonsam (hexamethylene bis in nomethyl 2 midazoline) also called phentola methylammonium chloride) Vethrum (oral) mine is a strongh adrenalyhe weakly sy mp3 Herameton (parenteral and oral) In contrast tholic agent Its action is very short fined 15 lo feiraethylammonium this drug in addition man hypoten ion is pronounced and st is im to it, marked sympathetic blocking effects has practical for use in peripheral arterial diseases also marked parasympathetic blocking action although at increases blood flow to the extrem The e undesirable de effects include con u ues It is however considered at present the palion (sometimes leading to paralytic aleus) best screening drug for ibe detection of pheo bladder atonia (cholinergic urinary retention) chromocytoma ? €1 and inhibition of gastric secrehonSuch side Priscoline (2 benzyl 4 5 imidazoline by effects and the marked hypotension and to a drochlonde tolszolme hydrochloride) is a par lesses degree impotence alter prolonged u e trally sympatholytic and posibly weakly ad have cau ed difficulties esen in the treatment renolytic agent with an alleged direct action of hypertensson 69 69 On prolonged use there on the vessel wall It has been given infra ar is marked fachyphylaxis 125 mg to 100 mg terrally in doses of 10 20 mg every 6 hours are the parenteral do es guien 2 or 3 times un It may be given intravenously in the same man 21 boura 120 mg to as much as 750 tag 4 ner or orally in doses of 25 50 mg cery times in 24 hours are u ed in oral admsustra hours 63 I is said to dilate muscle les els as Fion Great rautron is necesary in the pres well as skin vessels but we have not been able ence of coronary dises e Cerebrovascular ac to verify this by plethysmographic measure cidents congestie heart faslure and wremia ments Hypotension is not a problem The sy $ may occur following sudden withdrawal of the temic side effects 81 mainly burning of the skin drug Exceszne hypotension is counteracted are marked also wath entra arterial use proud by vasopres or drugs parasympatholytic ef ing the dose is large enough to mcrea e urlace lects bn Urecholine or neostigmine Herame temperature This is due to the fact that the thonium is a potent peripheral sasodstator and blush areas markedly participate in the re has alo been used in peripheral arterial dos sponse We have repeatedly observed leg pan 10 the aforementioned untoward side el immediately following one infra arterial or in fects however limt its use in this indication travenous administration of a ingle large do e to ar ile emergencies (75 100 mg ) this appears to be due to a de Pentolpyrrolidintam (1 methylpyrrolido crea e in mu cle flow that occurs parallel with mum bitartrate Ansoły sen pentolinum) Thurs increase in kin flow On the other hand there compound 15 more predictable in oral use has may be prompt relief of pain in s chemic ulcers le s cholmergic bloching effects than Hexame followed by slow healing <3 thonjum and is about fise times as potent" • Drugs wh predominantly ganglionic in producing simpathetic gangliomc blackage blocking action Its use in the treatment of hypertension is es Tetracthylammonium chloride (Etamon) table hed? Suhile it has hardly pa sed be is a sympathetic ganglionic blocking agent with pond suggestion in perspheral arterial disease pery little parasympathetic effects because of Neborylamine hydrochloride (mecamyla ease ·90 PERIPHERAL CIRCULATION IN JEALTIC AND DISEASE 80 min Inversin) is a newly developed ganglionic to any extent in peripheral 1a cular disease blocking agent that is not a quaternary am although they are capable of significantly in monium compound but a secondary amine It creasing blood flow to the extremities 84 85 is said to be well absorbed orally and to exhibit d Drugs in which the mechanism and the little anticholinergic and no adrenolytic action sites of action are still uncertain Its reported peculiar influence upon the vascu lar actions of epinephrine, liestamme and sero Apresoline (1 hydrazınophthalazıne) is tonin sounds interesting It merits further ex capable of lowering arterial pressure in man perimental and clinical work up It has a central action, but probably also di rectly affects the vessel wall B7 Vasomotor re Ecold (SU 3098 1 5 6 7 tetrachloro 2 2 sponses are influenced in an intriguing fa h dimethylaminoethyl isoindoline dimethylchlor non 88 89 It is the only hypotensive agent we ide chlorisondamine) This recently des eloped have tested which does not increase blood flow ganglonic blocking agent is capable of low to the extremities except alter sympathec ering arterial pressure and has the same side tomy in normally innervated limbs blood flow effects as the other bıquarternary amines but sometimes even decreases after the adminis to a lesser degree? Studies in man concern tration of Apresoline 39 87 ang effect upon blood flow to the extremities are not available at the time of this writing 27 VI (thosphosphoric e ter of 3 hy Preliminary experiments in the dog however droxyphenyltrimethyl ammonium odide trihy drate) The site of action of this drug is unde make it appear unlikely that Ecolid should be proven to be a good peripheral vasodilator lytic or ganglionic blocking that it has no termined It is said to be neither sympatho Peripheral resistance in the femoral bed showed a short dised initial decrease followed parasympathomimetic action and that it does not release histamine This information ſur by increase above pre experimental level in re ther states that one worker found marked in sponse to the drug crease in blood flow to the deeper tissues but c Drugs uith predominant action on the not to the skin in response to intravenous in Lasomotor centers jection another worker obtained satisfactory Ilyderginc is a mixture of dihydroergo clinical response with intra arterial adminis dihydrocrgochristine and dihydro tration of 10 20 mg in physiologic salıne We ergohryptint While ergotamine has been have not been able to obtain any significant in known to act as a va oconstrictor in some was crease in blood flow to the extremities in te cular beds including tho e of the extremi sponse to single intra arterial doses of 10 20 ties 74 the hydrogenated alkaloids of ergot mg are capable of depressing constrictor tonus by Arlidine (1 p hydrosyphenyl 2 1 methy) inhibition of the vasomotor centes. They are 3 phenylpropy laminopropanol) is introduced also said to exert a weak adrenolytic ac as a vasodilator of the adrenaline ephedrine tion? 8 They have been u ed in hypertension series It is said to increase cardiac output and as well as in peripheral arterial disease 79 8 coronary flow 90 as well as muscle blood flow ! Reports have been somewhat contradictory Good clinical results in intermittent claudica The dosage 105 mg 3 to 1 times a day by tion have been reported $2 doses used range either the intramu cular the oral or the sub from 6 21 mg orally 4 times a day lingual route Then considering the mode of administra Veratrum utride and album and the lar hion of the e drugs we have to differentiate be tween the acute and the chronically progressive 1ous preparations derived from it are likewise occlusion predominantly centrally acting vasodilators 63 In acute occlusion whenever there is any They have their established place in the treat ment of llypertension but have not been u ed reasonable hope to restore primary circulation cornine ·91 COLLATERAL BLOOD SUPPLY through a surgical procedure this should be intranenups Injections for any prolonged pe attempted Where uch hope does not szem siod of time is obriously impractical Intra rea onably founded the use of measures to mu cular stjections may be given by the pa induce reflex acodilatation ahould be tried tient himself or a member of lus famıl even Dirty laminoethanol the vacacne compo then the mean a considerable disruption of pient of procaine is an injectable alcohol that everyday living has been effective in our hands in this indica The Sarious drugs ued to produce pe tron usthout producing postural hypotension ripheral 1a odulation have different sides of ac It is gnen every 4 hours intravenously in tron Prescoline for example dilates hin ves do es of 1 Gm diluted in 60 ml of water Ita sels in bolk the glomus and blus: as for a mode of action in producing va odilatation 35 hort time while Dibenzılıne has a marked not known and la ting effect on the glomus artasand none Of the ganghonic blocking agents he same on the bush area ) Tetraethylammonium thonum is very effective in do es of 10 25 mg chloride may under circumstances increa e intravenously It marahly leads to increase surface temperature in glomus areas of the in blood how to the lower extremujes 8 This skin and decrease muscle flow at the same beneficial effect is frequently off et by sud time C# us exactly the ame has been ob ered der sciere hypotension włuch makes its uc when Priscoline was given in a single intra puters is especially in patients with general arterial or infrasendu, do e Careful study of ured atherosclerosis Similar considerations the precific situation on hand aids in elect appls to the use of pentolinium (An oly sen) in in the proper drug and continued observation doses of 2 3.mg intravenously indicates nect ssary changes in the therapeute Tetraethslammonium chloride on the other plan hand rarel produces signuficant lowering of The theoretical argument has the vasodila realing arterial pressure but usually does pro tation produced as generalized and therefore durt marked postural hypotension Its absists bound to disert blood from the needing parts to increa e peripheral blood flow is mferior thus deſealing the therapeutic purpose to that of hexamethonium pentolinium and sounds very rea onablt However studies by diethylaminoethanol If used antravenously ceveral groups of imestigators indicate that 57 mg per kg body weight is giten the responses of various s aseular bed are au Intro arterial administraron of hs tame lokomous and pecific it is known that wher Prascoline 27 VI and other drugs has been eser a vasodilator respon e can be eluled at adsocated in our land re uls late not bees all its magnitude is tersely proportional to encouraging resting blood llon (the smaller the installow Tht chrontalk progresne type of occlu the ligger the reponse) and that spontane son 1 In far more frequent Here measuri ous efforts of the organem at descoping col hurch can be applied continuously for many Islrral circulation which we are attempting to months and rear and which interfere as little enhance by rutiing off va acon krietor im 1. prosible with the patients actssities are ob pul take place jut where primary channel you's desirable The e requirements are ac have been pecluded We have been impres ed tualls met by oral preparations only e pecially by the effectuenes of agents of the Dibena br tho e which have a low rate of excrelios mine group that are capable of bloching adre and where a quasa permanent effect may be sergic impal es at the ve el wall possibly at ached with a round the cloch arrange the termmul points of chemical tran mi sion ment of admin tration *ithout too frequent the neuros a rular Snap e Interruptions of the patients day or night Two oral adrenergie blockers that have been Such applex for example to the Dibenamine marketed are Dibenzy line and Idar Do e re dern aus Toue rt peated intra arterial or quirement tasy conssderable from indussdual 94 0 ·92 I FRIPHFR 11 CIRCUI TIO INFALT AND DISEASE innocuous to individual ranging from 30 300 mg for plare in prolonged medication so that discon Dibenzyline and from 75 230 mg for llıdar tinuation for thus rea on only rarely becomes Adrenergic blocking a_ents have maskerl pligs IL Cessary nologie effects and are consequently far from (4) Genito urinary Tract The occurrence of erection and orga m without ejaculation has of the unde irable side effects encountered some may be explained by excess physiologic the younger age groups The explanation 19 been reported by most of the male patients in action while others must be attributed to tox sity of the drug for the individual patient in all probability, the mechanism described by Hotchkiss" whereby the completely auton (1) Respiratory tract Drynes of the throat omously innervated external sphincter does and stulliness of no e una ordable when not permit ejaculation while the Internal blockage is elective never constitute a reason phincter which is innervated in part by cere for discontinuation of medication occasion bro spinal fibers permits e cape of the ejacu ally if they are very annoying reduction in late into the bladder do c may be necessary Bronchual a thma or 15) Gastrointestinal tract Mau ea dar ang di order predi po ing bronchial spasm tha and occasionally somiting may occur represents a clear contraindication to the use The occurrence of true intolerance is small of adrenergie blocking agent (not more than 19c) Mot patients who ex 12) Cardioiascular system Tachycardia is perience early intolerance may do well after a commonly encountered effect on adrenergic inttial reduction of do e with very gradual in blockage Its mechanism is unexplained Spec cred e A patient may not tolerate one adre ulation and consequent experimental approach nergic blocking agent and may tolerate an may take two main directions (a) the lachy other well cardia could be related to decreased coronary Wlood flow (b) it might be related to the spe SURGICAL MEANS cific audity of the heart mu cle to ab orb and The idea that resection of a diseased part tore epinephrine and norepinephrine · Clin of an artery (arteriectomy) may relieve vaso cally the tachycardia cau ed by adrenergic prasm in collateral vessels and improve circula blocking agents often decrea es during pro lion distal to the egment was first expressed longed admını tration it is succesfully coun teracted by the imultaneous administration of by Leriche 7 V e of this procedure in trau matic urgery has been reported Rauwolfia erpentina preparations and hardly Surgical procedures de igned to enhance the eier necesitates di continuation of medica development of collateral circulation have been tron Thi pre ence of arrhythmias including aiming at interruption of sympathetic path auricular fibrilation jy not an absolute contra ways Aerves have been blocked with anes indication to the u e of adrenergic blocking thetics or alcohol for diagnostic and therapeu agents bul calls for increa ed caution in dos tic purposes Accordingly uch injections have age and very clo e ob crvation Marked drops been employce where it is desired to tempo in resting arterial pre sure are very rare in re rarily bloch sympathetic ganglia and nerve pon e to adrenergic blockade po tural hypo The block is applied at the tellate ganglion tension however may become a problem for sympathetic denervation of the upper ex (3) Central nerious system Drowsine s tremities and at the lumbar ganglia for the not onlrequently pecially in the el lower extremities Various anesthetic drugs derly patient J: mechanı m is not clear that have been u ed include procaine hydro though it is a umed to be related to changes chloride (Vorocaine or cocaine) Mety caine in blood dt trbution within the va cular sys Hydrochloride Neothesine or pijrocaine) Remarkable adaptation usually takes Vonocaine Formate Intracaine Hydrochlo t occur tem ·93 COLLATERAL BLOOD SVIPI.Y 10) 110 side Apothe ene lydrochloride \y locate tron of warmth fu hing and anludrosis over Ifydrorhloride (hdocaine) herylcaine (C) the lower extrematy on the injected srde As claine Hydrochloride) and piperikocaine far back a 1917 Lerickel) tried to interrupt (Lucane Hydrochloride) 5 100 The effects of sympathetic pathways to a hmb by stripping the sojection may la t from one hour to ses the main arterial trunk supplymg s Effects of eral days depending on the drug used and the thes removal of the sympathetic periartersal individuals susceptibility to st plexus were very short laed Nonadays pre Absolute alcohol in C phenol in water ganghonic sympathectomy has replaced this henzyl alcohol and Bromsalı ol are used when and other po iganglionic procedures at is desired to produce prolonged blockade los sympathetic denersation of the upper lastsg for one to six months or longer These extremity the stellate ganghon (lased superior Agents destroy Rerve tissue by their sclerosing cenical and first thoracic gangla) and the Action The sclero ed nerse tissue that under second thoracie ganglion are removed This goes Wallenan degeneration regenerales after may be done by an anterior 103 or a po terior karying period of time An objechonable fea approach 104 16 and the reader as referred to ture of alcohol injections is a painful neuritis textbooks of surgery and neurosurgery for the that frequently follow- sisu e and > altrskated various technes employed to the fibrosus at induces Interruption of the sympathetic innervation The stellate ganglion (a fusion of the in of the lower extremity is accomplished by se ferior cervical and first thoracic gangha) lo section of the fort econd and third lumbar cated behind the vertebral artery in the space paravertebral gangla These ganglia are ac lietween the transverse process of the eventh cessible through an anterior transperitoneal cervical vertebra and the neck of the first rib route a posterior retroperitoneal ap is subjected to blockadt in order to relele proach !!! and most popular lately through an tasospastic condition of the upper extrema anterior entraperitoneal procedure 1611 tres head and face for tht various approaches Interruptiori of sympathetic pathways to a and technics the reader is referred to excellent limb is as a rule followed immediarely by s descriptions on the subject in texto Ade palpable increase in warmth and a wible red quate klockade is indicated by the production dening and striking drynes of the skin These of Horner s syndrome (mosia ptosis of the up clinical ob ervations logether with marked per eyelid, and light elevation of the lower sncrease in surlace temperature led to under led enophthalmos conjunctis al snjection an standable enthusiasm for sympathectomy hidrosas on the face and arm and increase of In the election of patients for sympathec surface temperature) on the injected side tomy various factors are taken into consider Paravertebral block of the lumbar sympa ation Patients over 60 years are poor sub thetic ganglia us done for teraporary relieſ of jects for the operation Patients whose dif 1axospastic conditions of the lower extremites ficulty is exclusively intermittent claudication The lumbar sympathetic ganglia le on the an do not stand to obtain any benefits from the terolateral surfaces of the bodies of the cor procedure In such cases houeer where the re ponding lumbar sertebrae A generally ac occlusion is high les liac or high femoral) cepled technic is to introduce the anesthetic of where there are esidences of impending agent by 2 posterior foule trually at the site gangrene in the di tal part of the extremity of the econd lumbar sympathetic ganglion sympathectomy is believed to be }u pfied by This produces blackade of the L ganglia ame surgeons !!! " Other workers believe due to the diffusion of the drug upuard and that the operation is mo tuelul when the ar downward along the fascial plane For details te raai ob truction is ds tal indications include the reader is referred to texts on anesthesia the pre ence of a small nonhealing ulcer small Adequate blochade is indicated by the produc localized gangrene limsted to part of a toe rest 113 ·91 PERIPIIERUL CIRCULATION HEALTH AND DISEASE urt pain and what the < authors feel to be its pre anesthe la confirms the inadequacy of the cursors namely coldne and paresthe la operation The e te ts have been in u e for There is a difference of opinion as to the a long time It appears however that a more benefits derived from sympathectomy Some claborale omen hat cumbersome procedure surgeons use it only as a prophylactic mea may be more reliable in a certaimng the com in two types of ca es 1 where there is pletene s of denersation achieved This pro cimically obvious sympatheclic hyperactiv cedure con ists e entrally of mea uring the 2 where a potentially hazardous situa Te pon is of the denervated limb to va omotor tion with respect to the arterial supply may stimuli It is an e tabli led fact that sympa arise during or shortly after grafting These thienc denervation is followed by marked al surgeons find that intermittent claudication kiration of va omotor responses localized ulceration and rest pam are seldom Crushing of somalıc nerves carrying cuta significantly favored by the procedure nor neous su ation to the arca ha licen found to does its earlier performance contribute to the offer some relief in certain ca es of Buergers succes of local amputation in the foot Ir It di ea e with excruciatingly painful lesions The appears that such prophylachic preparation of nerves subjected to the procedure are the the patient may be accomplı hed to at leat uperficial and deep peroneal the po terior the same degree by pharmacologically induc tibial the ural and the saphenous nerves 117 ing adrenergic blockade The management of functional arlerio pas As clinical u e became wide pread di ap tic conditions calls for little further explana pointing experiences due to lack of improve tion Whenever the cau e can be found and ment or relap e alter initial relief became removed such a in the cervical rib or Scale more frequent A considerable body of physı nus Anticus syndrome the treatment is of ologic inte ligation has accumulated which course surgical 118 1 Medical means to lessen helps to under tand the above mentioned coure vasocon tractor tonus may be u ed freely of events (See Part I) Raynaud di ea c seems best managed with The adequacy or completeness of sympa sympathectomy followed by the prolonged thetic denervation to a part is gauged by ele peroral u e of adrenergic blocking agent vation of the surface temperature a visible In erythralgia the only seriou though rare flu h and abolition of sweating in the part Tasodilator type of regulatory di turbance A Where such changes do not occur their pro pirin and cool environment are still the be ! duction by a paravertebral block or spinal one has to offer ·IPAMENT OF EVOUS DRUIVACE 95 2 hosis 1 199 Chapter 3 Management of Impanment of Venous Dianage VEDICAL MEANS considered mea are preventing further 1 Disturbances so deep venons chan thrombus formation in other places hence it cannot be considered to any large degree a nels Phlebihs and Tenous thrombosis are clo ely related and almot invariably appear aleguard again the pecurrence of embolic as one desea e proces: 314 It appears that phenomena It mas howeser ke sell argued occa onally the inflammatory component can that mot pulmonary embols tem (Tom thrombi in the lower extremities ko that for be prompti alleviated by ue of the antt in flammatory agent phenylhutzzone (Butazoli example ligalon of the vena cava inlenor dine) It is recommended that in the earls may be considered a rather formdable pre acute tale e pecially in the idiopathic ca e Tentne measure") 2 The ind putable en 600 mg of phenylbutazone be gren on two dence that the we of anticoagulants has signifi Succes se days If improvement is not dra cantly deertased the mortality rate from pul matic the attempt should be considered a fail monary embolszation due to venous throm ure and di continued I there is marked re mi son of pain redne s and swelling withun There are two types of anticoagulant drugs 21-48 hour the do e may be cut to 300 mg ararlable the heparin type and the coumarin and medication continued for one week Pa tyze tents treated with pheny i ustazone must be Drugs of the heparin type haic a markex? checked daily for fluid retention blood counts effect on whole blood clotting time. Their ac hould be done repxcatedly to detect early the tion while cluelig antithrombie sa to a much rare pecursence of bone marros depression les er degree al o antsprothrombic and anti Anubiolies may be gren sy teme reaction thromboplastie 1-3 They are administered in marrants their use travenously or intramuscularly Determination T} time honored procedure of resting the of clotting time is simple but unpredictable involved limb in an elevated poaltion still has a fluctuations are troublesome especially with place m the trealment of acute venous throm the intramu cular Use The latter madı olad bo 1$ There is a growing tendency to mobilize ministration is also quite painful Two syn the patient as early as possible under the pra thetic heparin lhe compounds have been tried tectson of anticoagulants and with the ve of Treburon 3) and Parilo 134 Both produre elastic bandages or a Unnaboot marked allergic reactions in a high percentage The aspect of treatment of deep enous of cases 13 133 thrombo is has changed radically with the The chacal u efulness of he perıdın'$se adient of oral anticoagulants and the develop mains to be a certained Initatenous tryp in ment of well workable recimens incorporating is not recommended for the considerable haz the u e of both the parenteral (feparin) rupe ards connected with its u e 135 and the oral coumarın) type of drug The coutnarin type anticoagulants are in The main reasons why anticoagulant ther general taken by the oral route there are some apy has become the first choice of mort nork preparations permulting intrasenous use Their crs in the held and of the overwhelming ma action is mainly upon prothrombin activity jority of the medical public eem to be mea urement of prothrombin time is therefore 1 Ceneral recognition of the fact that throm ued a rude in their clinical administration hoembolse di pa e isa os temc rather than Although the inerea e in knowledge of details a localized condition It thus appears logical concerning the clotlang mechanı m of the that ligation of elected 1e els cannot be lood has been folloned by an increa e in ·96 PERIPHERAL CIRCULATION IN HEILTII AND DISEASE known details about the specific actions of tionship of dose to effect is largely unpredict everal of the coumarin type anticoagulante able 1 3 141 the method of checking on their effect has rc Many antiprothrombin agents have been de mained essentially the same Prothrombin may veloped since Linh? 3 and his co workers dis be expres ed in percentage of prothrombin covered dicoumarol as the cau e of hemor concentration The latter is assumed to be rhagic sweet closer di ease in cattle Re normal (100%) when the prothrombin time cently Verner Brodie and Burns puble hed 15 12 econd 134 137 The therapeutic range their thorough comparative study of hypo is said to be between 10% and 30% of nor prothrombinemic agents 8 of which appear mal We hould not overlook the justifiable to be clinically usable Table IV shich indı critici m which points out the confusion cates the differences in dosage as well as in time caused mainly by the variety of methods used of action is taken from their publication The in the per cent manipulation ' 1 134 It is rec 8 clinically usable agents are arranged in pro ommended that prothrombin activity be ex gressive sequence according to the time pre sed in terms of prothrombin time in ec clap ed between admını tration of a single onds using a thromboplastic preparation that clo e and the maximum effect produced in pro gives prothrombın time 13 16 seconds for the longation of prothrombin time normal control The therapeutic range is In the acute case or where there is a hi tory the n between 25 35 seconds prothrombin time of previous embolism it is adu ed to admin should not be permitted to exceed 10 second 1 ter heparin intravenously about 100 mg It is recommended that the ame laboratory be esery 16 hours for 21 18 hours Simultane u ed for follow up in any given ca e to keep ously an oral anticoagulant should be tarted conditions of determination con tant If a slow acting drug (eg dicoumarol) » It is likewi e recommended that parallel used intravenou heparin should be adminis prothrombin time determinations be per tered for 18 hours in the event a fast acting formed in diluted as well as undiluted plasma coumarın drug (e: Tromexan) is cho en because after a do e of the anticoagulant pro heparınızation may be di continued after 21 longation in the undiluted plasma might be hours equivocal while in the diluted plasma a pro Shapiro and Weiner 3 have tried to obrate longation definitely beyond the range of the the difficulties arising from the unpredict control might be apparent thus permitting ability of the prothrombin time trend by better evaluation of further dosage to be changes in the method of administration of used 133 141 oral anticoagulants Instead of a moderate in It is obvious that the oral route is preferable tial do e followed by a smaller maintenance to intravenous administration whenever treat do e a large initial do eis administered Daily ment has to be continued for any length of prothrombin time determinations will then time providing the orally taken preparation is how the peak of effect la ting for everal days well ab orbed Such is the ca { with the cou followed by a downward trend when this marın type anticoagulants Their disadvan downward trend is establi hed maller tage in urgent cases is the elapse of consider hoo ter do e is given and repeated when nec able time before the first do e becomes effec tive This difficulty is met by using intrave How long anticoagulant therapy should be nous heparin simultaneously with the oral an Lept up in a gnen case is a question of clinical ticoagulant the latter being continued under judgment Three to four weeks may be men prothrombin time control and heparin being tioned as an average for the acute case how discontinued when the oral drug has become ever the cour e of the local equelae of throm effectise The other major difficulty encoun bosis the general tatus of the patient and the tered with oral anticoagulants is that the rela occurrence of complications are the main mod a е аг ·97 PER VEENT OF ENOUS OK 41 SGE Table 1 Drug Doe Me Tale of metaboli m Day of real Prothromt 1 rrcosen Tromexan 1630 1 2 25 per hour G 23 3,0) 70 12 3 Siensten lan drone 350 2 10 per hour Dicourro? 400 13 5 5Ter day Cumopytan (63) 150 23 56 Warfars (4) 03 56 374 per day Varcoumar 21 6 Drparin 28 7 may be ulating influences Where the picture of b Relatue chronte thrombophlebutis or the pot phle Hutory of bleeding ulcers of the GI tract bitie syndrome develops prolonged use of advanced kidney disea e Coumarin type anticoagulants extended for The danger inherent 39 anticoagulant ther months and even years has been adyo aps as bleeding Frank somelimes maine cated 143 144 It is agreed among workers in the hemorrhage mas occur from an organ or or field that ngidity of laboralory control gan system The rechami mofita Orcurrence relaxed in the e cases for three reasons | The 1$ unknown Occassonally bleeding due to con maintenance doses used are usualls compara treh small 2 The desired prothrombin time mars drums may occur below the safety level of 10 econds undiluted prothrombın time and level as lower than in the scute ca e 3 In most in other cst no bleeding may occur above thus patients a pattern of re ponse to the drug de level The changes in coagulabulily of the I lood kelops such us fairly constant As a rule an per e certainly do not explain the occurrence indis adual pattern of drug administration can of hemorrhage while they may explain of be establelied on which the prothrombin time copre continuation of otherws e induced remains within the desired range (around 30 bleeding second undituted) Once such a pattern has In the esent bleeding occurs one of the meas Irene tablished it is ufficsesst to have the pro ures to be takes us the translu ion of (re thrombu tume determined eser) 23 weeks blood This hould be done in l leeding from Conradications to the use of anticoagu both types of anticoagulant ? In bleeding due to coumanın type drug intravenou, injec a bsoluri tion of 75 mg of uitamın or preferably 20 Aline bleeding of a kind including 50 m" of the more effectste h, orally or in purpurin manife tations impaired laer func tratenou ly 13th repeatedlyf neces tion plac zhromt oss and embolt m blood 371 1 3 141 In bleeding due to heparin re dicta w with impaired clotting pres frated mirenons of Protamine are Andi naney mala firme ter lants are 13 (aled 1341 ·98 I FRII IFRAL CIRCULATIO IV HEILTII AND DISEASE rapy that Salicylates and sulfonamides are synergistic may be the deep or the superficial ct Such with anticoagulante Fudence has been shown thrombosis may heal completely with re ti for hemorrhagic action of alicy latest and for tutio ad integrum" or it may cau e permanent their hypoprothrombinemic effect 117 Salicy! obliteration of the ves el producing impair ale therefore hould not be ued concomit ment of the venous drainage of the part As a antly with anticoagulant A synergistic action rule this is after sarying period of time com of sulfonamides with anticoagulants as Jeas well pensated for to a greater or le ser degree bv e tablishedt 3 ut great caution is definitely ad the development of collateral ves els which by visable The mechanı m conceivably in olies pass the occluded egment Where this does the destruction of bacteria normally re pon not happen soon cnough or to an adequate de sible for the synthesis of vlamın "? This gree various signs and symptoms attributable might be trut for all bactericidal thu to insufficient venous drainage become minilest is orally admını tered Vitamins h and h, and in the involved part 101" methylated xanthines (caffe in the ophy llın If the thrombus is friable poorly adherent theobromın) are antagonit of anticoagulants to the ves el wall with a tendency to further The influence on blood coagulation of ome propagation a crious stuation ari es as hierche commonly u «d drugs may present difficulties emboli may be thrown repeatedly into the air in the intitution of anticoagulant therapy in culation Pulmonary emholization of repeated patients receiving the c drus Since patients or ma site may be fatal IT here the throm with cardiovascular disea in whom antico bosis is accompanied by marked inflammatory agulant therapy is contemplated may vers fro change the thrombus may be firmly adherent quently be receiving xanthint derniatries it is to the ves el wall and is thus less likely to cause well to remember the enhancing influence on embolic phenomena However iſ the clot is blood coagulation of the purine base Peni infected suppuratic changes and liquification cillin contrary to initial reports does not in necrosis will cause fragmentation of the other crea e coagulability of the blood 119 119 Eu se adherent thrombus and eptıc emboliza dence to show an influence of Digitalts upon tron follows leading to pulmonary infarction blood coagulation has been unconvincing and suppurative metastasts el ew here as well 2 Disturbance in superficial venous as a generalized cptic pyemia There i con channels Inflammation and thrombosis in Dancing evidence that whenever serious embohc uperficial venous channels is never of alarm phenomena including pulmonary infarctions ing clinical ignificance except as a diagno lic occur in thrombotic disea e they almot in cue in early obliterative thromboanguitis In variably ari e from thrombo es in the deep the pre ence of considerable varico ite eleva Teins of the lower extremities 1 31 tion of the foot of the bed (lo in ure permanent Conservative including tho drainage throughout the night) i adw ed and designed to favor venous return flow (es the u c of ela tic bandage to restrict filling and tles ation of the insolved limb) the use of antı prevent further di tension of the dilated chan bionics and anhcoagulant therapy are em nel ployed in the management of thrombophlebitis may be very helpful in general \Vhere the e mea ures appear con SURGICAL MEANS traindicated or insufficient senous ligation 1 Disturbance in deep senots clan abose the ite of ini olement which can effec nels Venous thrombo Occur as a re trvely present the emholic phenomena & well ult of phyical trauma chemical injury ieg az check the pread of the proces may be following injections) exten ion of infectiou re orted to 1 6 163 When many venous channel foci as 1 complication following parlurition in a region are involved at the same time (r and other pregnancy states and after pro po tpuerperal or po talvortal seplic pelle longed bed confinement The veins insoked thrombophlebita ) ligation of the inferior sena mea ures ·99 PRVEYT OF YOLS DA414CE state 16917 cava is the operation of choice Detail of the Hale quartine na thon Honolate and Su ot qus surgical procedures may be obtained from test Hontier clero ing theram (pecially when hooks on operative technic 164 u ed alon has leen di appomuling in the lons Either preoperatiels of in the elent 2 run 17 1 + Injection se actions were innt infre more evitnile urgical procedure of venous quent and recurrence dut to redilatation of the Ingation appars contraindicated a le s radical thromlo id egment a well a reeanalızalon proct dure has lan employed namels ngsanal ol ille thrombus ka rather coramon symprthetic bloch Stimuli arising from the Ligation and re ection of varico e veins ap thromisophlebutic segment apparently cau e the pears to be the operation of choue Depending excitation of 12 con inicior inipules that are on the ite of the inoked veel the pro Iran miked through the sympathetic fibers 1 dure is done on the lon saphat nou vem at which in turn produce va opam of the in the fo st orals a It einptie into the femoral soked so el and its accompanying arter 165 Tein or on the front aphenous teiua 11 drains 167 Sympathetic block interrupts the e va o into the poplite al vein on the popliteal face con tractor impul es thus relies sng the spa tic In enler ca < the principal tribularse of the tell to lie re ected are carefully di ected 2 Disturbance in superficial venous ligated and ruled Alter to action the re channels Thrombophlebitis involving uper masing dh lal portion of the 3835) fu risber ficial 1815 is u ually managed adequately with obliterated in a clerosing injection or re ron ervate mea ure including clevation of moved by Irapung Tht procedure may be the affected frmh the ve of analyt ses ympto done with a Haio extrabummal inpper or the maticall and antibiotics sn the pre ence of superior Vliers nutralumsal fluible verstrip ssfection The application of oft tsc compres per "The de red length of tripped sian bandages may fe beneficial in ome ca es from its urroundmuses beneath the un The administration of phenylbutazone in de broker skin with the ue of the intrument Wed do es of "00 mg dails has been a clul in mei ton t» mg done at the stem of the stremi the hands of one worker Because of the lies of tht removed egment bensgn courfollowed ły superficial throm Linton called alltation to the important bophlebits the more radical mea ure eg role the commumcaling, 11 594 play us the fuer anticoagulant therapy and venous higation are i tence of varico e veins ans the production as a rule not indicated of 1ario ulrer In the prette of com Surgical management of varico e ressa may petence of the e sem a sece ar that uch be accompli hed by tko merlod u ed angle se el ke alot olated and heated i or a combpaljon ysgation with varying de The trealment of chronic Is apy dena h. grees of resection of the varico e vem and the beers in and large un alt foctors I'y scal If} cloon of clero ing olusione The relatne mea urts with a elevation of the lub c and implicity of the injection procedure and initial of the foot of the bed and the u t of ela dc reports of good re ults made it very populas bandage as by of temporanı alue sa the The varico e lein are oblsteralt d by the entro parls tage in fully sk plop elephantia as duction into the son of a clero sag olution or in Vilroy s di ae the does not offer any Corting and products an adherent relie «hile arex 3) mea ares hort of radual thrombus in de these el The olutions u ed remaal of the true ma est han not been include odrum morrhuale gratifying bal au 1 odium gnocar ·100 PERUT IFRAL CIRCUI ITION IN HEALTH AND DISFISE Chapter 4 Therapeutic Measures Influencing Primarily thie Minute Vessels To date the carch for an agent capable of Primary ner grouths of the rascular system demonstrably repairing damage to the capil are bet managed only by surgical excision lary wall or predictably influencing capillary The treatment of liemangiomas lymphangio permeability has been in vain mas and sclero ing hemangiomas depend Symptoms arising from regulatory disturb upon their location and symptomatology 180 181 ances in the minuto circulation as seen in Benign tumors which do not cause symptoms chronic trenchfoot may be relici ed consid do not require treatment in the pre ence of erably with the use of pharmacologic agents of symptoms or retrogressive changes y ray or the nicolmic acid group* Physiotherapeutic radiation or surgical excision is indicated measure especially contrast baths may al o Glomus tumors 18 that are benign thouch be very helpful This is done by alternate im extremely painful are treated by surgical mersion of the extremity in warm (2 minutes) excision rarely amputation of one or two and cold (1 minute) water tarting and ending phalanges may be nece ary Malignant ele with the hot bath 179 phantrasis is very rare Telangiectasias as a rule are better left For hemangiopericitomas183 sluch are quite alone Collowing trauma honeer & spider prone to become malignant and especially with telangiectasia may purt occasionally from the such malignant tumors as hemangiosarcomas underlying arteriolar ve el This is compara (hemangioendothelioma) 184 and lymphangio tively rare occurring in about 10% of all arcomas 185 early radical operation is the only spider telangiectasias and is best taken care of liope even then progno is is always guarded by surgical ligation Blood transfusions have However cases with a protracted cour e and to be given for the acute ancmia that frequently survival of many years have been reported 184 occurs in Rendu o ler s disease (livoid heredi Becau e of the multiplicity of lesions in ha tary hemorrhagic telangiectasis) due to bleed posi s sarcoma radiation is the mo t commonly ing lesions Whenever the l»leeding le ion can used treatment in addition to management of be sualızed cauterization sometimes fol the anemia and an occasional surgical excr ion lowed by excision is indicated because of local symptomatology 187 188 ·101 CONDITIONS AND COMPLICATIOTS Chapter 5 Management of Underlying Conditions and Complications 0 TREATMENT OF GENERALIZED Contrary to some reports there is convincing VASCULAR DISEASE evidence that excellent control of diabetes sig Obliterative arterio clerol comprie nificantly reduces the incidence of vascular the complications It may well be that the majority of ca es pre enting signs symptom difficulties in achieving really excellent control and equelae of peripheral arterial in uffi of the diabetes encountered in most chinics ciency The enology and pathogenesis of the basic disea e arteriosclerosi is still largely are re ponsible for the existing differences in unknown thus making any attempts at its pre opinion regarding its va cular complications The que tion whether in a grien ca e the de vention or of ats sequelae at be t hypothetical gree of control of the diabetes bears a demon The management of the patient therefore be comes limited to a greater or le ser degree to strable relationship to the quantity and in ten ity of vascular complications is tall un treatment of the exi ting lesions Preven an wered 9 tive mea ures include keeping the body weight for as good a control of diabetes as po sible os It appears rea onable to strive dawn restricting the total intake of fat and Vascular lesions found in collagen disea es kreping up a rea onable amount of noncompet have to be understood as part of the basic dus itive exera e such mea ures being generally accepted as wise even with advancing age Eur turbances not infrequently they also respond to the adminitration of cortico teroids Where dence has been pre ented to how that exerci e such le ions have advanced arterial occlusion 1» a notable factor in enhancing the develop and its equelae they have of course to be ment of econdary arterial blood upply $1 1 9 The use of anticoagulants in the prevention dealt with accordingly Specific arteritides and endarteritides (eg and treatment of arterial occlusyon has re mained a controver ial subject to the date of tuberculous or syphlıtıc) are to a certain de this writing 189 196 It stands to reason that the gree amenable to pecific treatment provided buic conditions giving me to thrombus for the lesions have not progressed to obliteration mation vary with the tructure and function of the of the va cular tree involved Specifi TREATMENT OF RELATED part cally whether there may be hope to influence EXTRAVASCULAR CONDITIONS occlune di ea e of the peripheral arteries by The relations between Various neurologic le Buticoagulants depends largely on the question ions and blood flow are manifold and intricate whether the e drugo po ve 5 yasodılatıng po (Parts 1 and Part II) Some experimental in tentialitres Sugge tion in thi direction ha formation about the impact of vascular di ease Leen only indirect so far 197 198 It will require upon cerebral blood flow and in turn about a great deal of experimental work and much the relation hıp of cerebral blood flow to brain further clinical ob ersation before a conclusive metaboli m has accumulated especially since answer can be reached Kety de cribed his method of measuring blood In the pre ence of diabetes mellitus athero flow to the brain 09 13 Attempts have been mato is and arteriosclerosis tend to run a more made to influence cerebral blood flow for thera fulminating cour e than in the aserage non peutic purpo es 14 diabetic ubject The duration of the di ea e At leat three therapeutic tool originally obe ity and hyperten ion are influencing fac dew ed to influence blood flow to the extrem Posibly the age of on et and tie have been applied recently to cerebral hereditary aspects are of importance 03 204 la cular di ea e pharmacologic va odılation tors 1990 ·102 PFRIPTIFRAL CIRCUT "TION IN HEAITH AND DISEASE 10 o and In the majority serious 13 18 anticoagulant therapy 17 the slowing in rate * & in a marhed decrea e in cervical sympathectomy More ines cardiac output with consequent heart failure tigative work and clinical experience are re especially in the pre ence of compen ated heart quired before it will be possible to arrive at a diseac For this reason preoperative digitalı conclusive evaluation zaljon is adv) ed Vherever emotional factors seem to be re Surgical repair may be done in the rare cases ponsible for the occurrence of ya omotor dis of congenital A V aneurzem turbances of one type or the other psychiatric of ca es however this is not po sıble due to help hould be sought prouded the vasomotor the extent and multiplicity of the lesions One manife tations are or bothersome is limited to con ervatric measures such as the enough to warrant per se such action u c of rubber bandages for compression of the The importance of proper cardiologic inses u ually abundant ectatic superficial veins and tigation and diagnosis in every case showing convolutes Ligation or the use of sclerosing disturbance of peripheral blood flow is obx sous agents are not adued 7 from Part II Proper treatment of underlying In case of Paget s disease where hypervas heart disea c is often followed by rapid clear cularization has led to imilar con cquences as ing of peripheral manifestations an arteriovenous fistula digitalization and Careful hematologic work up (viz Part II) other means to enhance work performance of may likewi e aid in the therapeutic approach the heart repre ent the only possible approach Jtes of considerable intere I though not under Ischemic Ulars and Gangrene The necrotic stood at all that attempts to treat ca es of es part 1usually referred to as gangrene entral Ikrombophila with anticoagulants have Where this is localized and sloughs off an failed ischemic ulcer results True vascular sensitivity to cold can be uc The management of the e dreaded equelae cessfully treated with antihistaminic agents of occlusive peripheral arterial disease calls for Thic respon e to cold de cribed in l'art II which measures which may help to localize the necro characterizes the c rare ca e can be prevented is to limit or prevent its further exten ion to or mikigated by admini tration of an antzhi ta promote slougluing off of necrotic tissue and minic before expo ure to promote healing of the resulting ulcer There are no reliable figures available on MANAGEMENT OF COVPLICATING the incidence of gangrenous le sons due to ou SFQUFLAE OR DISTURBANCES IN clu ise vascular di ca e nor on the frequency PERIPHERAL BLOOD FLOW Bith which amputation of the limb had to be performed as a lıfe aung procedure in uch Arteriolenous fistula Spontanrou closure Be that as it may it appears that the of acquired arteriovenous fistula (arteriove over all picture has changed recently whule nou aneurysm) has been reported in rare in the incidence of uch comphcations has re tances 3 As a rule however surgical repair mained about the ame the indications for is neces ary to relieve the increa ed load on the major amputations may be reduced consider o and to prevent local senous tasis ably and limited to instances with massile or in children increa ed growth of the limb up very rapidly adı ancing gangrenous lesions plied by the involved ses els is an additional The u e of enzymes ( treptokina e strepto as a bath as a sequela which may be fore called by surgical dorna e) a a moi i compre closure On the other hand surgical closure continuous slow dnp or in jelly form has been of an acquired AV fi tula that has exı ted for hown to be sery effective in remouing eru dates from ulcers and sounds without trauma some time and where the circulation has al ready adapted to it may result in ri e in both tizmug normal tı te With minimal surgery limited to excision of systolic and dia tolic pressure and in spite of A са с heart + 93 ·103 CONDITIONS AND COMPLICATIONS all necrotic tissue and removal of seque tra es better control of the infection and surpris when pre ent and the concomitant use of the ingly rapid healing beneath the necrotic slough enzymes McCarty and Tollett 33 and VrCarty 15 Sery encouraging indeed It should be noted 31 reported very encouraging re ults in the that a triking feature in the e cases is the ap management of patients with chronic refrac pearance of pink healthy granulations that tory ulcerations of the feet due to arterio clero replace the pale 088) gro ly desatalized tis Sts with or without diabetes and in the sues at the base and ed.es of the ulcer Where presence of o teomyelitis in ome ca es the gangrenous e char has to be debrided the In the c ca es the increa ed sale of healing readine s with which bleeding occurs offers and repair occurred de pite the deficient blood clinical evidence of the increa cd blood flow in supply which the e investigators feel had re the area In some ca es penpheral pul es rear mained unchanged They a cribed the good peared in the coure of the administration of results to incrca ed dilusion of antibiotics the adrenergic bloching agent in the light of l»oth locally and from the circulation into the these ob ervations it appears that the favor area of di cac which was made possible by able change in the clinical coure of the e the enzymatic removal of the exudates They patients is attributable to an improvement in al o speculated that the enzymes might have their vascular supply primarily by the en relea ed locally some pecific factor of repair liancement of the development of collateral that are present but are inhibited by the ele circulation and secondarily by ome improve ments of disea e until the lyric effects have been ment in the orginally in ufficient primary vas accomplı hed cular channel That reparative proces es as The favorable influence of adreilergic block well as higher and more effectnc antibiotic ing agent in ca es with impaired arterial levels may become better available to the area circulation has been de cribed in the litera under these circumstances appears to be a logi ture 36 Wertheimer Redi ch and Stecle re cal consideration ported the marked enhancement of healing of The concomitant u e of adrenergic blockers aachemie gangrenous ulcers following the u e and enzymes yielded even belirr te ults in of Dibenzylıne "37 With the plethy mographic tho e ca es where we had occa son to u e them evidence of increased blood flow which they No conclusive figures are available at the time obtained in ome of the e patients during the of this writing, but it appears that a consider administration of the drug the e investigators able increa e may be attained in the percentage attributed the fasorable re pon e ob erved to of limbs that can be salvaged from amputation an improvement of the circulation They be by the combination of judicious u e of adren lieve that this was brought about by the block ergic blockade with the method deseribed by ing of the continuous afilux of adrenergic im McCarty and Tillett pules to the collateral circulation in (thoxe) The problem of secondary infection the limb with gro ly impaired primary circula cau e of so called "et gangrene has become tion They feel that the e adrenergic vasocon much ea ser to handle ince the advent of ulfa strictor impul es play a large role in prevent drugs and antibiotics Whenever po sıble ma ining the healing of ulcers terial from the pangrene hould be cultured We have ince administered adrenergic and specific sensitivity of the pathogenic or blocking agents to many patients with pe ganisms determined The cho en agent hould ripheral arterial insufficiency and complicating be u ed sy temically With the exception of 1 chemic gangrenous ulcers in whom amputa treptolina e treptodorna e up of medicated tion of the limb was held inevitable hy consult local applications i not recommended It is ang surgeons The favorable re ults olitained usually ineffectile not only becau t of impaired in more than half of the ca e with relief of ab orption but it may even produce loral ma symptom localization of the gangrenous proc ceration und irritation and thus cau e further ·104 PERIPIERAL CIRCULATIOY IN HEALTH AND DISEASE sue devitalization of the tissues The extensne use cerve as u eful guides in determining the even of antibiotics may enhance fungal growth at tual closure or nonhealing of the operatie the lesion a complication to be cautious's tump satched for Packing of the limb in ice must During recent years there has been a notice not be attempted as long as there is the light alls increasing tendency to acrifice less and et lope of aung the part Only when the less of the extremity in such surgical pro deci ion has been made to perform (after a cedure Amputation is performed as far di hort delav) amputation can packing in ice tally as posible with the provision that the be considered it dımını hes the ab orption of inci ion be done through relatively normal tı toxic sub lances from the necrotic parts and is quic helpful in combatting pain Details of surgical wchnics arc readily avail Proximal amputation i indicated when the able in standard textbooks on the subject It fingrent or necrotic proces has progre ed to may be well to reiterate howeser as Leermooth insolie the bone tendoni or joint capaule un and Sles or emphasize that in any operatie der which circumstances pontaneous healıngı procedure imouing limbs where arterial in unlikely The optimum level--minimum sacra ufficiency is the ba ic underlying pathology fice of the limb with rea onable a surance of a the minimum handling of tissue is of para healm, rump-at sluch amputation has to be mount importance In amputations performed performed is best decided on the operating berause of vascular di case they table The amount of bleeding ob erred 39 at trict nece ily of avoking tourniquet the u e the planes of inci ion and the gro s appearance of equal flaps the careful avoidance of con of the muscles ?" at the site whether pink and triction at the flap margins and the extreme healthy looking or ome and browni i importance of the gentle handling of tissue tress the 10 Rcfcrences-Part IV Sur I COODWIN JI Veir al treatment of peripheral va rular de ca e - the Fharmo ological ar proach Brit M Bull 8 31 19,2 2 I EARSONIL SIR JAD STESSOR I J fery in obliteratase arterial disease Brit 1 Bull 8 375 192 3 LERICHE RAND H112 ) Exterimental and clinicalla i for arterie tomy in treatment of localuzel arterial ol literations Am J Surg 115) 1931 4 CROSS RF BILL 1H JR AND I IERCE FC II Methods for pre ersation and tran plan tation of grafte graft in dog tran lanta tion of presersed gralt9 in 9 human (a e Surg Gynec & Ob t 88 689 1949 5 VOORHEES AB JR JARETZKI 1 II AVD BLAKMORE Use of tules con fructed from vynion N cloth in bridging arterial defects. Am Surg 13, 337 1932 6 L'ENVOYER GP Arterial embolectomy Surg Clip North Am. -66 1918 7 VEAL JR AND DUGA TJ Peripheral ar terial eml oli m Ann Surg 133 603 1931 8 OLHIS III Dre S AND JULIAY OC Lafe peripheral arterial eml olectory Ar h Sorg 66 480 1953 9 CHRISTOPIE J Resection of terminal aorta anl oth common thac arteries for en larteritis ol literan Acla chir Belg 1 56 1917 10 FLKI D CAD COOPER FJr Surgical treatment of insidious thrombo is 10 casp Im. Surg 130 117 1919 1 KEVLIY J Re ults of experimental endarteri ectomy hi tolonic study Vem Acad de cher 1554 1918 l' Herol! I AD LAVRY P Endarleriectomy of mac and al dominal aorta etc Archd mal du oeur 4 930 1919 13 BYLIE EJ KERR E. AND DAVIES O Fxperi mental and clinical etperiences with ue of fascia lata applied as graft about major ar teries after thrombo- and arterectomy and ·105 JAVAGESIENT AND THERAPY aneuryemorthaphy Surg Gynec. & Ofst. 93 957 1951 11 NUNETZ NA MILANES BAND POPRIGL EZ IJ Endarteriectomy or urgiral re toration of ob fructed artery in arterio clerosis of 1 terans Circulation 5 670 1959 15 BARKER W F AND CAVYOY J A Evaluation of endarteriectomy Arch Surg 66 488 1953 16 PABEL I Surgery of aortic bifurcation Press me) 58 214 1950 17 HOLMBERG L Surgical considerations concern ing circulatory du turbances in lower extrem ties of thromboangitic and arterlo-clerotic type Acta chir Scandinay 100 199 1930 18 SAYAYERSOY N Arteriectomy for arterial obstruction in extremities Geriatrics 6 12 1951 19 BEACONSFIELD P AND KENLIY J In idious thromlosis of aortic bilarcation 30 ca es Arch, Surg 66 336 1933 "O CAJIEN J L riche syndrome treated by fesec tion of aortic bifurcation results after 21 years Acta chir Belg 59 917 1933 1 COATES A E AND SYxOxps VI Arterial re section as adjunct to sympathectomy Roy Melbourne Hosp Clin Rep 19 51 1948 22 LOWENBERG K I SHUMACHER H B JR Ex perimental studies in vascular repair etc Arch Surg 59 74 1919 23 CHRISTOPHE LAND DALEY J Conservation by freezing of homo pecific heterogenous ar terial grafts. Acta Chir Belg 49 199 1950 21 SWAN HI ROBERTSON HT AND JOHNSON ME Arterial homografts fate of preserved ao tic grafts in dog Surg. Gynec & Obt. 90 568 19,0 25 1 5 FEVRE F Vanagement of occlusive arterial diseases of extremities JAVA 147 1401 1951 76 ALLEN AW The general management of cir culatory di orders of the extremities New England J Med. 201 839 1931 27 LEWIS T AND PICKERINC CW asodilata tion in limbs in te ponse to warming body with evidence of sympathet c vasodilator nenes in man Heart 16 33 1931 8 HIIRAMANY LG Passive Vascular Exprcises and the Conservati e Management of Oblit eratne Arterial Discases of the Extremities. Philadelph a Lippincott, 1936 29 BRANDUAN O AND REDISCH * Incidence of peripberal vascular changes in diabetes mel fitus A suney of 261 ca es Diabetes 194 1953 30 TEXTER, E CL JR REDISCI! TAND STEELE JV1 loduced intermittent claudication Am J V Sc 2? 653 1951 31 BLERCER L The Circulatory Disturbances of the Extremities Philadelphia Saunder 1924 32 LAVDIS E VI AD GIBBOY JH JR Effects of alternate suction and pressure on circula tion in the lower extremities Proc Soc Ex per BioL & Med. 30 593 1933 33 COLLEYS WS AND WILENSKY N D The treatment of pe pheral obliteratile arterial dis a ely intermittent venous occlusion a report of the re ults in 29 ca es JAVA 109 1960 1936 31 THP>04 JE AND VANEJ R. Effect of venous occlu ion on blood flow in cutremities experimental study and effect of venous occlu sion on peripheral arterial blood flow Sur gery 31 53 195 33 COODY C. IS AND COTTES Y J I am and its treatment in thromloangitis obliterans. New York I J 11 771 1923 36 WALLER LM AND ALLEY FV The usp of sulphur for the production of fever in pe ripheral vascular disease Ann Int Ved 5 178 1931 37 PAGE I HAND CORCORAN AC. Arterial hy pertension its diagnosis and treatment Chi cago The Year Book Publi hers, 1919 38 BARKER NW Results of treatment of throm boangiitis obliterans by foreign protein JAMA 97 841 1931 39 BEC P S U ual and unu ual reactions to protein (fever) therapy Arch Int Ved 49 1 1932 10 MUFSOY 1 A new treatment for the rehel of obliterati e di-ea e of pripheral arteries, Ann Int Viet 29 903 1918 41 FRAUIERZ AND SPIEGELBERG II Pharma kologi che Wirkungen des B I stidylcarbinols (Ntacol Roche) und serwandter Pyridy 1 erbindungen lekset Thy hol Acta 64? 1919 42 Pepi CH W AVD BRANDSAY O The one of Yasod lator drugs in chronic trenchfoot Anmol 1 313 1930 43 White S The Ta odilator - Roniacol Minnesota Med 33 133 1950 41 TICHTER I H FOGEL M. AND FABAYCANT II An cyaluation of Roniacol tartrate in arterin.

·106 PERIPATER IL CIRCULATION IN HEALTH AND DISEASE sclero is obliterans New York State J Med 51 1303 1952 45 GOODMAN L AND GILMAN A Pharmacolo. cal Basis of Therapeutics New York Mac millan 1911 16 LE SAR RA HOROWITZ O AND MONTCOMERY H Va odilator effects of intravenous Pro carne in patients with ischemic extremities Am J M S 224 300 1952 47 WEISS S WILKINS RW AND HAYNES FW Nature of circulatory collapse induced by sodium nitrate J Clin Invest 16 73 1937 18 WIKING RW HAYNES FWAND WEISS S Role of venous system in circulatory collar e induced by sodium nitrite J Clin Invest 16 85 1937 49 WERTHEIMER L REDISCH W HIRSCHHORN AND STEELE J M Patterns of urface tem Ierature re jon e to various agents Circula hon 11 110 1955 50 HECHT FH AND ANDERSON RB The nu ence of dibenamine (N N Chlorethylamine) on certain functions of the sympathetic nery ous sy tem in man Am J Med 3 3 1947 51 NICKERSON MGOODMAN LS AND NON CUCHI G I harmacologic propertte of a new adrenergic blocking agent N N-dit enzyl- 8-Chlorethylamine (Dibenamine) J Phar macol & Exper Therap 89 167 1917 52 NICKERSON M HENRY J W AND NOMAGLCHI GM Blockade of re pon es to epinephrine and norepinephrine by Dibenamine congeners Federation Proc 10 397 1951 53 NICKERSON M AND NO31AGUCHI GM Adren ergic blo king action of phenoxyethyl ana logue of Dubenamine J Pharmacol & Exper Therap 101 379 1951 51 PEDISCH TEXTER CE JR HOWARD RM STILLMAN PH AND STEELE J M The action of SKF 688 4 (Phenoxethyl deriva tive of Dibenamine) upon certain functions of the sympathetic nervous y tem in man Cor culation 6 352 1952 55 MOSER MWALTER M MASTER AM ME TRAUX J AND TAYNOUR PC Experience with Oral 689 4 (N--Phenoxyisopropyl-N --- Benzyl - B - Chlorethylamine Hydrochlo ride) a new adrenergic blocking agent Am Fed Clin Res Meet Atlantic City NJ May 1 1951 56 WERTHEIMER L. Repisc AND STEELE JM Effects of an adrenergic blocking agent (Dibenzyline) upon clinical manife ta tions of arterial insufficiency in the extremi ties Circulation 10 366 1954 57 MOORE PE RICHARDSOV AW AND GREEN HD Effects of a new Dibenzazepine deriva tise RO 2–3248 6-Allyl-6 7–Dihydro- 511-Dibenz (ca) Azepine Phosphate on the blood flow the peripheral re i tance and the re ponse to injections of epinephrine in the innervated hind limb of the dog J Pharma col & Exper Therap 106 14 1957 58 GOLDENDERG M SNYDER CHAND ARA VOY HI JR New test for hypertension due to cir culating epinephrine JAMA 13, 911 1917 59 An4Z4 AAND VARROLD VIAL J Detection of hypertensive pheochromocytoma by routine reline te ! Bull et mem Soc med d hop de Paris 69 506 1953 61 Sack II AND KOLL J F Difficulties in the diagnosi of pheochromocytoma limitations and possibilities of the regitine test Deut che med Wchnschr 79 390 1954 61 ORCAY ES Pheochromocytoma the value of certain tests u ed routinely in diagnosis Ann Int fed 43 11,8 1955 69 LIPPMANN III Intraarterial I riscoline ther apy for Teripheral ia cular disturbances Angiol 3 69 1932 63 WEITZMANN G The treatment of pheripheral circulatory di orders with Pri col Munchen med Wchischr 71 1599 1941 64 GRIMSON IS REARDON M J MARZON P A AND HENDREY JP The Effects of Pri col (2--Benzyl-45-Imidazoline II Cl) on peripheral vascular disea es hyperten von and circulation in patients Ann Surg 127 968 19-18 65 LYONS PH MOECK NELICH RB HVOBLER SW CAMPBELL KM BERRY RL AND RENNICK BB The effects of blockade of the autonomic ganglia in man with tetraethylammonium Am J MSc 213 315 1947 66 MASSELL B ADOLPHE AND FRENCIJ B The ue of TEAC as a vasodilator in peripheral -ascular disea e its effect on ym pathectomized extremities Circulation 1 655 1950 67 PATON WD AND ZAIMIS EJ The sharma cological actions of Polymethylene Bistrime thylammonium salts Brit J Pharm 4 381 1919 69 RESTALL PA AND SHARK F I The treat ment of hyperten on with Heramethonium New Zealand VI J 49 206 1950 ·107 BIANAGEMENT AD TIERAPY 69 FREIS E D FINVERTY FA, JR SCHNAPEX II AND JOHNSONP The treatment of hyret tension with Metamethonium Circulation 5 20 1952 70 FINNERTY FAJR AND FREIS E D Clinical apprai al of llevamethonium (C6) in peri Theral va cular disea e New England J Ved 213 395 1951 71 FREIS ED PARTHENOPE EA LILIENFELD LS AND POSE IC A clinical apprai al of Pe ta pytrilodinium (A&B 050) in hyper ten ne patients Circulation 9 510 1991 2 SVIRK F H AND ALSTED KS Treatment of arterial hyperten only Pentanethonium and Hexamethonium alts la ed on 150 te is on hyp rten ves of varied etiology and 53 pa rients treated for penods of 2 10 11 months Brit VIII 1917 1951 73 SMIRK FH The action of Intamethyl ne 15--u--methylpyrrolidinin bitartrate (V&B 050 A) in arterial hyperten con Lan cet 1 457 1953 74 Crust ON MS TARAZI & K AND FRAZER J E JR new orally active quaternary am motum ganglion blochin, drug capable of re ducing blood preure SU 30°8 Circulat on 7733 1935 15 WINSOR T The comparative effect of four gan lionc blocking agent on the cardiovas cular sy tem of man Am J V Se 230 133 1935 6 REDteci AND PELZER R 11 rapıllary tudie in migraine ellect ol er ataraine tar I ate and water diure 1 im Heart J 76 598 1913 77 II ALEY T. J AND IDEY M Compari on of capillary effects of ergotamine a d the dihy drogenated ergot alkaloids Federation I roc 10 1 1951 81 Popke RJ An evaluation of ome dihydrogenated alkaloids of ergot in the management of chronic perplieral vascular di case Angiol 2 111 1951 8? COETZ R II The action of Dihydroergocornine on the circulation with pecial reference to hy perten ion Lancet 1 510 1919 83 FREIS E D COLBERTSOY J W LITTER J HIAL PERIN V HI BURNETT CH AND WILKINS IL The hemodynamic effect of hypot nsive dru sin man I leratrum very le J Clin In vet 23 333 1919 81 HOUCLER SCORLEY P AND LARZA T C Fffects of Protoveratrin on the circulanon is hyperten on J Clin Inve 30 651 1951 8 REDISCH WERTHEISIER L DELISIE C AND STEELE JM Company on of s ceral and periph ral sa cular beds in hyperten ne pa fients their response to various typoten we drugs Circulahon 9 68 1951 86 SCHROEDER II A The effect of 1 hydrazinoph thalazine in hyperten ion Circulation 5 28 195 87 SIL YRARD A WERTHEIMER LAND REDISCH Studies on hydralazine end nce for a peripheral ite of action J Clin Inve 1 33 1987 1954 8P Freis E D AND FINVERTY F A JR Supprey. sion of sa omotor reflexe in man following 1 bydrazinophthalazine (C-5968) Proc Soc Ex per Biol & Med 75 13 1950 89 GRIMSON XC CHITTUM JP AND VIETCALF BH Actions of 1 hydrazı opl thalazine (C 5968) on va omotor rell ves and hyp rten on in dogs and man Federation I roc 92-9 1950 90 VIEWERS Vasodilatie aralkyls of the adren alıpel en edrene series Arch Exper l'athol & Pharmacol 273 983 1931 91 INSEL IP'er S AND COLOYHOFEN lluman mu le an I skin I lood flow The effect of a oactive substances Angiol 6 190 1955 97 POMERANZ J GADEK RJ TITMAN E RAND SCHERL S Therapy in intermittent claudica tron Angiol 6 271 1953 93 Redi CH W AND TANGCO Funpubli hed data 91 Durer4 AW Vedical management of acute and chroni arterial occlu on Bull New York Acad Med 28 11 1932 9) KAAB AV CICEE B Specific andny of the leart mu cle to al orb and store opine phrine and norepinephrine Circulation Res 3 553 1935 Some 78 KURICEK WGKOTTLE FJ FELDFA D4 LAKER DJ AND VISSCHER MB adrc olytic action of ce ta n ergot derisaties upon the circulation Fe! ch ift fur Prof E Fotblın Ba le Penno Schwabe 1918 9 FREIS F D STANTON J PLITTER J Cut EFATSON J II ALPERIY VH MOISTER FC AND WILMIN RT The hemodynamic elfect of hypoten se drugs in man II D hy Irocrgocornine J Clin Invest 28 1387 1919 90 TANDON KY TV Tle clinical effect of Dihy droerg cothine methan sulphate (DIIO 180) on arterial hyperten von Corculation 1 686 19.20 ·103 1 ERIPIIERAL CIRCULATION IN NIEALTII AND DISEASE 96 HOTCHIKISS RS PINTO A BAND KLEEGMAN 112 FLOTHOW PG Anterior extraperitoneal ap S Artificial in emination with semen recos proach to the lumbar sympathetic nenes. Am. ered from the bladder Fertility & sterility J Surg 29 23 1935 6 37 1955 113 PEARL F L Vu cle plitting extraperitoneal 97 LERICIIE R AND STRICKER P L arteriectomie lumł ar ganglionectomy Surg Gynec & 01 1 dans les arterites obliterantes Paris Va on 67 107 1937 1933 111 LEARBOVINJ Surgery on sympathetic nervous 98 ADRIAVI J Merve bloche A manual of regional sy tem Lancet 2 50, 1950 anesthe ta for practitioners of medicine. 115 I EAR3IONTIT J AND SLESSOR A J Surgery in Springfield Thomas 1991 obliterative arterial di ease Brit M Bull 8 99 SMITH DW Stellate ganglion block tis ue dis 315 1952 placement method Am J Surg 92 314 1951 116 WARREY R The diagno is and treatment of 100 SELDON T 11 Regional ane thetic procedures chronic obliterative arterial diseases of the ex around the vertebral column Anesthesiology tremities Practitioner 1017 218 1955 2 669 1911 117 SITIWICK RA AND WHITE, J C. Elimina 101 HAXTON IL A Chemical sympathectomy Brut fion of pain in olliterati va cular disease of 11 J 1 1096 1919 lower extremity technique of alcohol injection 107 LERICHE RAND lleitz J De la reaction vaso of sensory neries of loner les Surg Gynec dilatrice con ecutise a la re ection d un es Ob tet 51 391 1930 ment arterial oblitere Mem Soc de Biol 80 118 losov IW AND COFFEE, J R Cervical rib 160 1917 method of anterior approa h for relief of symp 103 GASK CE The urgery of the sympathetic toms by dist ion of scalenus anticus. Ann nerous system Brit J Surg 21 113 1933 Surg 85 839 1927 101 ADSOY AW Cervicothoracic ganglionectomy 119 TELFORD E, D AND STOPFORD JSB The vas trunk re ection and ramcectomy by the po cular complications of cervical rib Brit J terior intrathoracic approach Am J Surg Surg 18 637 1931 11 227 268 1931 120 OCITS ER A CAGE M AND DEBAKEY M 10. Apsov IW Changes in technique of cervico- Scalenus anticus (Raffziger) syndrome Am thoracic ganglionectomy and trunk re ection J Surg 8 669 1933 Am J Surg 23 287 1931 1'1 MAFEZICER HC AND GRANT T Neuritis 106 TELFORD E D The technique of ympathec of the fronchial plexu mechanical in origin tomy Brit J Surg 23 418 1935 the wcalenus syndrome Surg Gyner & Obst 61 722 1938 107 STRWICA RJ Surgical intervention on the sympathetic nervous system for peripheral vas 1) LoxD JERE W JA Surgical management of cular disease Arch Surg 40 286 1910 houlder girdle syndromes New operative 108 SMITHWICK RH The rationale and technique procedure for hyperal duction co toclavicular cervical rib and calenus syndromes Arch of sympathectomy for the relief of vascular Surg 66 69 1933 spasm of the extremities New Fngland J Med 22 699 1910 1.3 SILAPIRO SIL AND WEIVER M Coagulation Thrombo is 109 MACCARTILY CS New York Surgical procedures on the and Dicumarol Brooklyn Medical Pre s 1919 sympathetic nervous ystem for peripheral vas ular dispace In Allen Barker and Hines 191 ALLEY AKAYD DOYALD OY GA Venou Peripheral la cular D ea e Saunders Phila thrombosis and pulmonary embolism Bull delphia 1935 pr 665-676 New York Aca] Ved 24 619 1918 110 ApSaY IW AND BRONY GE The treatment 12 STEIN ID AND TOE OA Treatment of of Raynaud s disease by resection of the upper superfictal thrombophlelitis etc Arch Int thoracic and lumbar sympathetic ganglia and Ved 93 899 1931 trunks Surg Gynec & Ob 48 577 1979 16 ZOLLINGER RAND TEACH YOR # Late 11i Royle, MD The treatment of spa tic paralysis results of inferior vena casal ligations Arch by sympathetic ramısection experimental Surg 65 31 19,2. basi and clinical results Surg Gync & 127 BARKIR, NW Anticoagulant therapy in pe Obat 39 701 1924 ·109 DIANACEMENT AND TIIFRAPY Asin Serial pro ripheral vascular disease. Circulation 4 613 1931 18 BREDAR Sur le traitement anticoagulant des thromboarteriopathies oblitetantes chronique de membres Basel Benno Schwab 1951 199 BARKER NV Anticoagulant therapy in pe ripheral vascular disease Circulation 4 613 1937 130 MA\CIERE CI FACELBERC RAND RANDALL LO A new anticoagulant Treburon (Pol 3053) J Pharm & Euper Therap 107 156 1951 131 SOREN EY CW AND WRICHT IS thetic anticoagulant a poly ulfuric a id ester of polyanhydromannuronic acid (Paritol) Circulation 2 658 1950 13? HIRSCHOECK J S AND MADISON FW A compari on of the anticoagulant properties of a polyheturonic acid ester with sodium he parin J Lab & Cln Med 36 836 1950 133 WRIGHT IS Pre ent status of anticoagulant the apy in the treatment of myocardial in farction the ue and miu e of anticoagu Jant an evaluation of new anticoagulants their indications and dosage Ann Int Ved 1394 2955 131 BOURGAIN R SYMONS C. TODD Y AND WRICHT IS The action of Pho phorylated He perıdın on blood coagulation J Pharm & Exper Therap 10 393 1954 13) TAYLOR A AND WRICHT IS Intravenoug Trypsin Circulation 10 331 1951 136 QUICK AJ Phy iology and Pathology of 11 moxta is Philadelphia Lea & Febet 1951 137 OREN P1 Prothrombin and acce ory fac tors Am J Med 14 901 1953 138 WARE A CAND STRACNELL R Improved one stage prothromi in method. Am J Clin Path 22 191 1952 139 ALLEY J GILLIAN O CAND DRACSTEDT L. P Use of erial dilutions in determination of prothrombin by the one stage technic Arch Surg 41 813 1910 140 SJAPIRO SU REDISI M 11 AND CAMPBELL JIA Studies on prothrombin Proc Soc Exper BI & Ved 53 951 1913 111 DLFF I F.. GAMBLF JR VILLIS P Ilonc on PE WILSOY SAD Pot HEMUS JA The control of exce si effect by anticoagulant Ann Int Ved 43 953 1955 117 VEINER M BRODIE, B B AND BURYS I JA Comparative Study of llypoprothrombinemic Agents tbe Phytologic Disposition and Chemical Pharmacology Basel Benno Sch Habe 1955 143 WRIGHT IS AND FOLEY WT Long term anticoagulant therapy for Cardiovascular diseases Am J M Sc 136 217 1919 114 OWEN PA Long term Dicoumarol treatm nt in cardiova cular disease Technique and re ult Bacel Benno Schwabe 1951 115 L'ARXIV T Alp YALE WF Meutraliza tion of lleparin with protamine (Salmine) J Lab & Clin Ved 39 1396 1917 116 SHAPIRO SH RED> MH AND CAMPOELL, 11A The prothrombinopenic effect of salt cylates in man Troc Soc Exper Brol & Ved 53 wl 1913 147 COTLOVE E AND WORZIER J J thrombin estimations in cardiac patients di agno tic and thefat eutic implications of Dicoumarol Ann Int Med 21 618 1916 118 LEWIS J H., Effect of Penicillin on blood com agulation Proc Soc Exper Biol & Ved 63 338 1916 119 WEIVER M TELTMACHER AND SHAPIRO SIT The effect of Penicillin on the coagulability of blood Fyper Med & Surg 6 181 1918 150 BAUER G A senographic tudy of thromboem bolic problems Acta chir Scandinav 811 1910 151 BAUER C Poentgenological and clini al study of sequels of thrombosis Acta chir Scan dnar 86 1 1949 152 FRYKHOLM R The pathogenesis and mechan ical prophylar s of venous thrombo is. Surg Gynec & Ob 71 307 1910 153 HUNTER VC SWEEDEY VD ROBERTSOY TD AND SYYDER GAC Thrombo is of deep ve ns of leg Its clinical significance as eremplified in 351 autops eg Arch Int Med 68 1 1911 154 HLYTER WC KRYCIER I J KEYVEDY ) C. AND SYEDE WD Etiology and presen tion of thrombo is of the deep leg veins. Sur Eery ! 1,8 1915 153 Hossam J Thrombosis of the deep veins of the lower leg caus ng pulmonary embolism New En landl Med 211 993 1934 156 Cour's CG JOVES J RAYD NELSOY E. W Surgical treatment of pelvic thrombophlebitis Ligation of inferior vena cava and ovarian ·110 PERII NERAL CIRCULATION IN HEILTH AND DISEASE seins A preliminary report New Orleans MI &$ 19, 394 1913 157 COI LINS CG AND MFLOY EW l'hlebothrombot and throm! oplilebett in fine colony ond ol tesnics Am J Ob & Gynec 57 916 1916 158 MEICA JAND INCERSOLL F VI Thrombo phlel its and phlel othrombosi in fynecology patients their prophylaxi recognition and treatment Am J Olst & Cynec 57 938 1916 159 COLCC MELSOY FJOVES JR FINSTEN BB A TOV49 Piration of vena cava A critical evaluation la ed on & tudy of 3 ca e New Orleing & SJ 99 188 1917 160 ILOMANS J Diseases of the veins New Fng land J Vel 235 163 193 19 1916 101 MO ES FR Ligation of the inferior vena caya or alac sein I report of 36 operation New Fn lan! J Med 23, 1 1916 162 VEAL JR HIUSZY I II AND BARVES F I igation of the inferior sena cata in throm lo is of the deer seins of the lov er extremity Surg Gyner 8 ob 8160. 1917 163 О NEIL E E Lilation of the inferior vena casa in the prevention and treatment of pul monary embolim New England J Ved 232 611 1945 161 DEBAKEY VF The Blood es el In Cole XI Operative Teclınır Tol 21 New York Ippleton Century Crofts 1919 16, DEBAKEY BURCII CEAD OCHISTEX A Nect of chemu al jrrilation of renou es ment on peripheral pul e volume I roc Soc Frper Biol & Med 41 585 1939 166 OCUSNER A AV DEBANEY Throil ophile Tots The role of s&so pa m in the production of the clinical manife tations JIN4 114 117 1910 16 OCH VERA AV DEBANEY 11 Intravenous clotting and its sequelae Surgery 14699 1913 168 DEBANEY II AV OCHISVER1 Nosorain sym pathetic block method of therapy in thrombo phlebiti 4 Alabama II 87 1911 169 OctVER A 490 DEBIREY Y Treatment of thrombophlebitis by nosocaine Ilock of sym pathetics technique of injection Sure ry 5 191 1939 10 OCUSVER AND DEBAKEY I Therapy of Irch phlel othrombor and thromt ophlebiti Surg 2009 1910 171 OCITSVER 4 AND DEBANEY Therapeutic con iderations of thrombophlebitis and phle bothrombo 1 New England J Med 2' 07 1911 1/2 DETALY VC Tartco e leins In Cole & Il Operatase Technic New York Appleton (entury Croft 1919 173 VYERS TT Sclero ing Therapy in Wien Marker and line Peris heral la cular Dis ea e I hiladelphia Saunder 1955 111 OCUSER A lanco iti of the Lower Extrem ay In aller TI Lewis Tractice of Sur fory Tol I. Hager tonn Prior 1956 173 IITOS KR The communicating veins of the loi er let and the operatne techniquc for their ligation Ann Surg 10. 58? 19,8 16 WRICHT IS la colar Di ea e in Clinical Practice Chicago Year Book iu hers 1918 177 LIVTOV BRAND REFLEY ) The Tot phletic varicose ulcer Surgnal treatment with pecial reference to the coinmunicating vein of the lower leg Am Heart I ll 27 1939 1.8 PRATT G II Surgical correction of lymphr dema application of new operative technique an luph stasis and allord conditions JIV 4 157 888 1953 119 ALLEN A W The general management of cir culatory di ordere of the extreme New England J Med 201 859 1931 180 BRONY I BAND FRYER VIP Treatment of hemangioma Arch Surg 6) 11. 1999 181 4 DRENS G C DoyounOS AN AND I'ost CF Treatment of angiomae ummary of 0 years experience at Columbia re ytenan Medical Center 1mJ l'oentgenol 0 273 1932 182 LENSER TE Glom tumors summary of 15 ca e Irch Surg 57 531 1918 183 SrCUT Hemangiopericytoma study of - nen ca es Cart er 7 1027 1919 181 Srour AP flemangio endothelioma tumor of blood esl featuring va cu ar en lotl eltal cell Ann Sur. 118 41) 1913 185 STEWART PAND TREYES N lymphangio arcoma ett Cancer 1 61 1918 186 11CCARTHY DAD I 4CK CT Valignant blool veel tumor report of 56 rase Sure Ginet & Of 191 165 19,0 181 AECERTER EF AND PLALE AR haposi s sar etc ·111 SLANAGEMENT AND THERAPY coma criti al survey Arch Path 31 113 1912 188 HERBLT PA Pathology Philadelphia Les & Febi r 1997 189 Nichol, F S FALK OP J., VIES FLLY GR. AND HILLL E. Anticoagulant therapy in car diovacular di ea e panel di culon South HJ 12 913 1919 190 VARLE, CD AND WRICHT IS Diseases of artering and arteriales In Vod in Treatment New York Smith & Werner 1953 191 SCHILLINC FJ Anticoagulant in myocardial Inlarction JAVA 143 783 1930 192 Bong JF Inticoagulants in cardio a-cular Jiseap Minne ota Vled 35 101" 19 > 193 RI EX III Crit cal evaluat on of anticoagu Tant therapy in tr atm nt of acute myocard al infarction Inn Di trit of Columbia 2 7 1953 191 VICCREERY J 1 AND VCREERY E) Anti coavulant therapy in acute arterial thrombo 19 (complcating pelic urpry) South Dakota J Vel & Pharm 6 1 1973 1) WRICHT IS VARPLE CDN BECK DF Vyorardial infa ction 19 clinical manifesta tion and treatment with anticoagulants lew Torh Crune & Stratton 1951 196 VILLIKACII.. SEEXERT TC 4 STECK 111 Stu be in cerebrisa ular deae Proc Staff Veet Varo Clin 30 61 93 116 186 1955 197 Giti ERTI CADALETSN 1 Th effect of th anticoagulat drug upon the coronary low J Lab & Clin Ved 33 1153 1918 193 VFLSON T F. JR. CASTROVOVA E. ASD Fly VAN C The effof Dioumarol on the tran ascular change of T 1P'lat led pro tein in raflits. Grculation Res 430 1976 199 Witsos JL, Root HF AND VARLE, A la cular lesion of d abeties Am J V S 2'1 19 1931 00 RICKETT HIT The problem of va rular de eae in dialet mllitus Proc im Dal coc 8 1.3 1918 01 VIAJOR SC Blool pe ure in diabele mel Ach Int Vied 44 97 1993 _ DOLCER 11 Clinical evaluation of vascular damage an diabetes mell zu JAVILA 134 1 9 1917 03 DICER Factors influencing premature car dio axular dg neration in diabetes mellitu In Program in Chical Endocrinolo Mew York Grune & Stratton 1951 20: ADLER RERC D PARETS ID is Boy E.D Hereditary a pect of athero-cleroi P'roc Am Dial oc 913 1919 05 VARELL, 4 Present-day treatment of diabetes in the finention of drgrietative complca tion J Ath y Soc 41 69 191 206 Poor IF LISEN RII., 49 741C* R Factor in the rate of developm nt of va cular lesion in the kidney retinae and peru heral Tecel of the youthfuldhabetic Am 3 Die 1 D. 17 119 1930 201 LAWRENCE, RD la cular changin laleles Brit WJ 2 101 1950 208 DLYCA GG Diabetes mellitu Pula del nhua Saunder 1951 909 KENNEDY F, WORTIS S BAND WORTI I Clical e idence for cerebral sa-omotor chan in circulation of the brain and pinal cord Research Tery & Vent D Proc 18 6 0 1939 10 LETY SS HAFLEX CHIEL, J 11., JEFFER W I LEOPOLD I HAND SUEVIY II A Blood Пок 3 cular res tance and otygen con ump tion of the brain in eent al lypert non JCI n losest 11 1918 211 KEY SS Circulation animi tabulam of the human train in health and d ac Am S Wed 8 05 1950 a 212. SUENNIS H4 T01ACA P. COLLBOFF B SOFFE AV AND BCRTIN L The effe is of per arteris d roul an hyperten on upon the cerebral cir ulation J Clin Invest 3' 159 1953 13 T'cutis F A Ta o pa man focal ce ebral 1-chemia an experimental tul Arch cur & Pych +1191 ?11 R I AND LLCACY E II Cerebral la cular Diae Tew York Crune & Strat ton 1930 13 ILMAN T. RO E BERC I AD FAZEKAS JF Effect of hltamine on rerel ral hemo dynamics and metabolim Irch Neurol Pch 61 301 190_. 16 JAYNE W. SCHEINBERG P Pick VE AND BELL, V S The effect of ntravenous Papa Terine Hydrochloride on the cerebral circula ton, Jain In et 31 lil 193.. 21° SCHEINBERG P The effect of notini ac don the cerebral circulat on etc Circulation I 1149 1950 ·112 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE 230 TILLETT VS Studies on the enzymatic ly is of fibrin and in ſammatory exudates by prod ucts of hemolytic streptococci Springfield Thoma 1951 218 BATTEY L L HEYVAV AAND PATTERSOY JL JR Fffects of ethyl alcohol on cerebral blood flow and metaboli m JAMA 152 6 1933 219 WRICHT IS AND MCDELITT E Cerebral vas cular di ea e their significance diagnosis and present treatment including the selective use of anticoagulant sul stances Ann Int Med 41 688 1957 290 FAZEKAS JF KLEI J AND ALMAN PW Evaluation of current therapy in cerebral vas cular disea e J Chron Dis 2 508 1955 221 DE TAXATS GAD GRAUPNER GW Emerg ency treatment of apoplety Practitioner 164 212 1950 222 STERK The pathology of apoplexy a criti cal review J Neurol & Psych 1 76 1938 223 DRY TJ AND HIORTOY BT Traumatıc arterio venous fi tula insolving the nght femo ral artery and vein pontaneous closure Arch Surg 33 248 1936 24 GALLANDER 2 L Study of Arteriovenous fis tula with an analy is of 417 cases Johns Hopkins Hosp Rep 19 239 1920 225 ILOLMAN E Arteriovenous aneurysm At nor mal communications between the arterial and senous circulations New York Macmillan 1937 226 IIINES E A JR AND WALGU JM Congestive heart failure the result of arterio venous fis tula I roc Staff Meet Mayo Clin 11 545 1936 727 LEWIS D D Congenital arteriovenous fi tulae Lancet 2 6') 1930 928 ROBERTSOV CH W Chronic ulceration of the leg considerations in local and general meas ures in treatment M Clin North America 39 1301 1955 231 VILLER J M CINSBERC MLIPIN RJ AND LONG PI Clinical experience with strep tokinase and streptodorna e JAMA 145 620 1951 232 VCTAY LV JR AND SPRUNT D IT Strepto kinase and Streptodorna e in the treatment of diabetic gangrene Arch Int Med 87 551 1951 233 MCCARTY RAND TILLETT S Strepto kina e Streptodorna e in chronic infections of feet involving bones and joints Surg Con North America 32 405 1952 231 VICCARTY WR The enzymanc-surgical treat ment of chronic infections of the feet in dra betic and arterio clerotic patients Surg Clin North America 34 415 1954 233 HA1OVICI H Clinical applications of adren ergic Llockade in va cular di ea es with pe cial reference to Dibenamine and 688 4 An giology 2 531 1951 236 MOSER M PRAVDOVI A CORDISOY J A AND VATTINGLY TW Clinical experience with sympathetic blocking agents peripheral vas. cular diseases Ann Int Med 38 1245 1953 237 WERTHEIMER L REDISCHI W AND STEELE J M Effects of an adrenergic blocking agent (Dibenzyline) upon clinical manifestations of arterial insufficiency in the extremities Circu lation 10 366 1954 238 GIORLEY R A Amputation in occluste vas cular di ease In Allan EV Barker NW and Hine A E Jr Peripheral Vascular Dis. ea e Edi Philadelphia Saunders 1916 239 McCARTY #R personal communication 10 LE ARMOYILJAND SLESSOR AJ Surgery in obliterature arterial di esse Brit Bull 8 375 195? 229 TILLETT VS SHERRY S CHRISTENSEX LR JOHNSOY AJ AND HAZLETVAST G Strep tococcal enzymatic debridement Ann Surg 131 12 1950 ·Part V The Anatomic Basis of the Penpheral Circulation in Man OR THE CONCEPT OF THE MACHOVIESH AND MICROVESH AS ILLUSTRATED BY THE BLOOD SUPPLY OF MUSCLE IN MAN Ny R L dec II Saunders, MD, FRSE,J Lawrence, BSc, D A Vacıver, MD. RCN, and N Memethy, MD S" Various ways INTRODUCTION to find their way into the mallest vessels at INCE WUSCLE comprises approximately pre ures comparable to the blood pres ure of 12° 0 of the total human body weight we man Such injectants demon trated the va cu consider the blood supply of human muscle a lar patterns of human mu cle and kin in a way not hitherto observed Moreover such pictures matter of major importance The detailed na ture and arransement of the peripheral es el quickly revealed that previous descriptions of of man here demon trated microradiographi muscle ve els were both inadequate and mis cally for the first time make it evident that leading by rea on of the u e of coar e inject much phy Jologic and pathologic experimen ants (fig 1) tation of the past being ba ed on inadequate EXPERIMENTAL PROCEDURE anatomical knowledge of the peripheral vas During the pa t four years we have tudied cular patterns mu t be regarded a pecula the va cular patterns in mu cle in the following tion To any thinking medical man at hould be obvious that until the correct anatomic basis is introduced into the study of uch va cular 1 In order to di play the gro ser features of problems as hock burns and the like patho the muscular ve sel we injected fre h human logic and clinical deductions must suffer An caddiers with a contrast medium Within everal illu trated report demon trating the e hitherto hours of death A standard x ray unit was then inviable vascular patterns was submitted to the u ed to take both traight and stereoarterio National Research Council of Canada in Janu grams of the intact limbs as well as the excised and 1 olated muscle groups The po ition of all A review of the literature on the subject muscular ve els was recorded during the dis revealed that very little was known of the blood section and compared with the radiographic supply of mu cle in man' and that much of findings Aeries of over 50 stereoarterio the available information was ba ed on animal grams of this type was taken The combined experiments Hence it was decided to work on u e of radiopaque injectants of small particle fre h human material and by radiographic ize and a high hilo, oltage radiological tech arteriography to attempt to demon trate mus nic account for the marked va cular detail ob cle ves els in their entirety Initial attempts to lained completely inject se els within mu cle failed 2 The tudy of the finer detail of the intra but further experimentation with radiopaque mu cular se els in injected and erci ed mus agents led us to conclude that only fine grain cles was performed by means of microarterio injectants containing particles as mall a graphic technics Vu cle preparations were smaller than the blood cells could be expected placed beneath a Phılıp $ x ray diffraction tube 113 ary 1995 or

·114
PFRIPUFRIL CIRCULATION IY JIFALTII AND DISEASE
تک دی
Fuc 1 VOSCILOGRAMI OR GRO - IRTERIOCRAST OF 1 ECTORALIS MAJOR
The gro
Tht illu trates that conventional large ja tulle injectant an rescal only the major artene
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re el of a icht pe tora) url a thi are a
mirror image of its left counterpart compare th the left p teral forn in tim even thout
the muscles are from different sulject Vale 7 years

·LIITOMIC BINIS OF CIRCULATION 115 in order to ecure the ofter v rays of lovger Sascular patterns they form within the various Have length and exposures were made on fine mu cles of the body Initially our objective grain emul ion plate Multiple exposures were was the study of the intramuscular vascular necessary in the case of larger mu cles in order patterns of man but it oon became evident to permit scrutiny and photographic reproduc that a knowledge of the extramu cular at tion of the entire intramu cular vascular lied rangement of my cle ve els was an e entral Enlargements of the resultant microgrterio corollary to an under tanıdıng of the se cls grams were then made by photomitrographic within mu cle methods Material from over 21 foetuse and In view of the inadequacy of modern text 30 adult subjects has now beun tudied by the book tatement we were forced both to re ex above the method amine and to re determine the individual ar 3 Microarterro-raphic experiments were terial supply of all the skeletal mu cles in the al o carried out on living animals (rat rah human body More recently the careful de ec bit) in order to tudy the micro copic vessels tions of Salmon (1935) came to our attention of liung mu ck and to correlate the functional and we were able to confirm many of his ob er behavior of the e vascular patterns with tho c vations The volume of material so accumu een in man Variou mu cular flap and win lated makes it neces ary to pre ent the extra dows de igned to minimize reactive error as and intramu cular arrangements of the mu cu much as po sille 3 were u «d on both the trunk lar ve els criatim and to deal with only the and limbs of the c animal The technics so major and clinically important trunk and er evolved for microarteriography of insing mu tremital muscles (le wall be the ubject of a later report Although ome early work was carried out by Wollenberg (1915) 10 on the lower limb 1 Microcirculatory studies were al o car ried out on a number of animal (rat rabbit) mu cles Campbell and Penneſuther (1919) mut be credited with the first radiological using the fu ed quartz rod method of allumin study of arterial di tribution in human mu cle ating luing to ue This ersed to confirm cer They publı hed a short account of their radio tain ob ervations revealed by microarteriogra play and gave a working knowledge of the be graphic inte tigations into the blood upply of mu cles with pecial reference to war surgery havior of blood flow paths in living mu cle un der various conditions and drew up a clasification of the lumb mus cle» ba ed on the number of source of supply Similar ob ervations were made on the pe ripheral circulation and arteriovenous bridges prestou ly mentioned work of Salmon no fur and ana tomotic potentialities Other than the in the living human foetus ther interest seems to has been shown in the 5 Stereomicroarteriography methods de ubject until the conclusion of the lat war veloped in this laboratory wert alo u ed in when Le Gros Clark and Blomfield (1915) order (a) to tudy the malle t intramu cular studied the effect of gun hot wounds on the effi res els in the third dimension (b) to remove ciency of intramu cular ana tomo e in rabbit dilficulties of interpretation occa joned by the mu cle These workers appreciated the prac uperimpo ition of shadows inherent in flat tical importance of the subject and concluded film radiography and (c) to determine the their study by stating that a knowledge of such volume pattern of a mu ele patterns would be applicable to muscle surgery and the treatment of wound but that E\TRAVIUSCULAR ARTERIES fortunately mnie preci e informaron is yet Little attention has been paid to the coure di ailable as regards man Following on the and mode of di tribution of the maller arler Power (1915) 9 Hughes (1918) 11 and Edwards le that upply the keletal mu cle of man and 11933)! reported on the various clinical ca es til les to the ana toniotic connections and that aroc from their wartime experiences un ·116 PERIPIIER IL CIRCULATION IN HEALTII AND DISEASE Fic VUSCL LOCRAN OF PECTORALIS MAJOR This shows the ana tomo ing arterio arterial arcades which form a pro s va cular nett ork or macromesh that erists within all muscles Some of the larger veins are al o usille Demonstrated ly using fine particle (05 micron) injectants at phy hological pre ures mime lately after death Compare with fig 1 and employ a mirror to detect the lateral ymmetry of the gro intra mu cular arterial patterns in the human Female 68 years ·117 ANATOMIC BASIS OF CIRCULATION ie which were illustrative of the effects of mu cle to have been overlooked because the dissector ischaemia they also discussed various anatom was apt to display only the larger vessels while ical points that appeared to have hearing on the microscopist tended to concentrate his at the vulnerability of certain muscles tention on the finer terminal features of the Anatomical textbooks give a very limited Fessels as seen in a ection However the de account of the blood vessels supplying muscles velopment of the previou ly described radio in almost all instances they dismiss the subject graphic technics have enabled us to study a in a general manner Only the larger named larger vascular terntory at one time ranging muscular branches and a few muscles recente from a tissue field 12 to 5 in diameter an any pecific mention while for the rest little entire muscle or even a region of an intact more is said than that a given artery gives of limb Moreover we were able not only to image muscular branches to the adjacent muscles these vessel in their intact state but also to ob Gray 13 for example merely remarks that each serve them stereoscopically muscle has a very rich blood supply derived These tudies have revealed that muscular from muscular branches of neighboring arter arteries both major and minor show a quite He then continues with certain incorrect remarkable constancy of radiographic pattern observations to the effect that the e branches in their extramu cular course which naturally are inconstant in arrangement and have no reflects a regularity of their origin and di tri communication with the blood ve sels of other bution This is readily discerned in compar structures in the neighborhood Similar state able mu cle arteriograms made on different ments are made by Morris 14 although this text subjects and such is the characteristic arrange differs by remarking that the distribution of at ment of the major arteries lying in a given least the main branches of the arteries is fairly muscle that in a hort space of time the ob constant o that fields of vascular supply may server comes to a sociate a certain basic pat be mapped out Piersoll and Cunningham tern with that muscle also treat the subject in a limited manner But while both surgical experience and an The inadequacy of textbook statement ap atomical atlases attest to the regularity of dis pears to tem from reliance upon de ection tribution of the major named muscular ar alone as well as from uncritical acceptance of teries examination of a series of muscle arteri Spalteholzs (1888) early account of the dis ograms impres es one with the constancy of tribution of blood vessels in muscle (which the arrangement of many of the minor and un however was almost entirely ba ed on the rab named arteries Such vessels have quite un bit and the dog) While acknowledging the derstandably been largely overlooked where re beauty of some of Spalteholz s cleared prepara liance has been placed on dissection alone but tions of animal muscle we must not overlook the e smaller or segmental arteries cannot as the fact that he confined his tudy to isolated will be seen be ignored simply because a some mu cles which may account for uch an un what larger artery appears to assume the prin warranted generalızation as that each mu cle is cipal role for they constitute an integral part va cularly a elf contained unit Unfortunately of the blood supply of that mu cle and can be his work was applied without qualification by demon trated with regularity subsequent writers to the human musculature Of course minor variations 10 origin oc Despite the cla ic nature of his work it must cur although many repre ent no more than dif be held re ponsible for certain of the misunder ferences in length of arterial segments We tandings now current concerning the blood have encountered few that appear to be of any upply of muscle and its relation to urround major significance when considered from the ang ttue tandpoint of the blood supply of a giien mus The e entral character of the vascular pat cle or mu cle group Variations in vascular terns of human mu cle and kin would appear pattern naturally attend development and ·118 PERIPIIER IL CIRCULATION IN HEALTH AND DISEASE growth but preoccupation with developmental of the given individual and surprisingly con irregularities of larger ves els has unfortu stant from individual to individual regardless nately cau ed many to overlook the surprising of race age or sex Moreover the e arterial constancy of the ultimate va cular pattern of patterns are established in later foetal life and man both in respect to his major and minor agree with those observed in the adult muscu ve sels Variations in origin of a principal lature (cf fige 3 and 4) it is instructive to muscular artery may in some instances con compare such vascular patterns in muscles such FIG 3 MUSCULOCRAM OF FOETAL DELTOID MUSCLE Compare the va cular network within this fo tal mu cle with that of th adult d lord (ie 4) The e intramus ular patterns are establi hed in later foetal lıfe Foetus CR 21 8 cm Ace 6 month cervably determine muscular reaction to ar terial occlusion but this is only likely to apply to such muscles as fall within Class 1 of our classification (see below) Arterial distribution to skeletal muscle i in general the same on both sides of the human body with the re ult that the vascular pattern observed in a mu cle (eg the right pectoral) is almost a mirror image of its left counterpart (cf figs land 2) Using the methods de cribed ahore it has been delermined that all the shele tal mu cles exhibit a characteri tic arterial pat tern that is bilaterally symmetrical in the body as the deltoid trapezius or greater pectoral It may be assumed that there is a genetic ha is for these vascular patterns of muscle but this should probably occasion no more surpri e than the recognition that similar factors deter mine the ultimate form of the heart Briefly it would appear that the development of the arterial patterns in mu cle have been ignored in favor of the study of larger vessels Our radiographic studies revealed that the muscles of the trunk and limbs are generally supplied by segmental arters which ari e either from the main arterial ares or their ·119 ANATOVIC BASIS OF CIRCULATIOY FIC 4 VUSCULOCRAST OF ADULT DELTOID Vuscle Compare the intramuscular la cular pattern with that of the foetal deltord (tg 3) Vale , years major named or unnamed mu cular branches egmental arteries pa ing to the long fleshy at (fig 5) Such egmental arteries u ually range tachments of the exten or mu cles of the leg from 1 mm to 3 mm in caliber and are o and the long egmental arteries that supply the numerous (but regular) in arrangement and freely moving uperficial flexors of the fore similar in caliber in different mu cles that the arm This egmental pattern is immediately idea of a haphazard supply can be di counted obvious in certain muscles (es ubralis ante The length of these segmental branches nat rior leg etten ors) where a ladderlike eries urally varies but it eem to be related to func of mall egmental arteries can be cen passing tion For example comparison may be made to supply succeeding areas or segments of these between the short extramu cular course of the mu cle (fig 6) Such egmental arteries Le ·120 PERIPHERAL CIRCULATION IN HEALTH AND DISEASE three or more mu cle bellies (eg hamstrings) or else it may traverse a muscle directly in order to terminate in another muscle Then too a segmental artery may supply skın directly or do so after piercing a muscle or two mus cles or it may fork to supply both skin and muscle Such arteries often fork to supply the muscle belly and its related nerve while cer tain det ply placed segmentals supply both mus cle/and periosteum Accordingly we recog nize purely muscular segmentals musculo cu taneous segmentals and neuromusclar seg mentals any of which may arise from either a main arterial axis or its larger named or un named branches Hence the blood supply of skın uhcutaneous tissue mu cle and bone is closely interconnected In stereoatteriograms for example (fig 7) it is often possible to trace one limb of a forking segmental to the subcu taneous vascular net and to trace the other limb to the intramuscular vascular network and thus be able to observe the interconnections between the intramusrular and subcutaneous vascular networks (fig 8) This is contrary to Spalteholz s statement that the blood supply of a muscle should be regarded as an isolated unit The blood supply of a muscle belly appears to be related to it volume Thus certain me dium sized muscles are supplied solely by seg mentals derned from an adjacent arterial axis while other larger muscles are dependent on both a main arterial axis and a large named or Fic 5 MUSCULOGRAM OR CROSS ARTERIOGRAM OF AN unnamed muscular branch which together en ExciseD BICEPS BRACHII MUSCLE compass the muscle and so provide necessary Shows five segmental arterie passing from the segmentals upon opposite aspects Quite often brachtal artery to supply that must le Note the length large and hitherto unrecognized intramuscular of these segmental and also their intramuscular dis arterial axes descend centrally within a mu cle trilution and ana tomo es with one another belly to provide intramuscular segmentals (eg gastrocnemius tibialis posterior triceps bra have in various ways Some spend themselves chu) In some instances a given muscle may entirely in the related muscle and often divide derive its segmental upply from multiple a rey into ascending and descending rami either that do not necessarily lie on the ame aspect upon or within the muscle to form a series of of the limb This is allustrated by the perforat anastomosing arcades with their fellow seg ing segmentals that pierce the interosseous mentals at hugher and lower levels membranes of the forearm and leg in a regular Segmental arteries end in various ways A manner to supply muscles in the opposite com segmental artery for example may end in a partment The clinical significance of this is muscle belly or it may fork and supply two or that ischaemic changes may be encountered in ·121 ANATOVIC BASIS OF CIRCULATION Fic 6 STEREO ARTERIOGRÁN OF LEC This shows a ladderlike series of sermental arter e ja ing to the uttals anterior and leg ex tensors from anterior tibial artery View with a pochet stereo cope (C6 Ze , No 6004) There some p ctorial lo due to the marked reduction and reproduction mu ces on the side of the limb opposite to the pended on coar e injectants and was thus found obliterative phenomena eg tibialis anterior to be both inadequate and incomplete when ap Thus stereographic study of segmentals that plied to the a e ment of mu cle arteriograms pass to undisturbed muscle and skin in the in prepared with fine particle injectants The fol tact limb uggest that improvement of the lowing groupings hould prose of practical va cular upply to an extremity following sym value in both clinical and investigative proced pathetic denervation must be for the whole ures since attention has been paid to both the limb and not in a preferential manner for the anatomical and functional feature of the mus skin alone The probable limitation of im cles mentioned as well as to their extra and in provement in muscular blood supply if any tramu cular va cular patterns could be attributed to the unyielding nature of Class 1 Free muscle belly with the urrounding deep fascial envelope grouped supply A new classification of human skeletal mus Con ists of those muscles that have attaclı cles La ed on the arrangement of their blood ments of limited area and hence po tess a upply has therefore been e tabli hed since freely mos able belly--and that dernie their earlier work (Campbell and Pennefather) de major blood supply from a short or localized

·122
PERIPHERAL CIRCULATION IN HIFALTH AND DISEACE
FIG 7 STEROARTERIOCRAW OF BACA OF TINCI Obere that
femoral artery segmentals for lo uth 1 oth the intramu cular
an alcutaneo la cular nets ark The perforating I ranches
of the grofinda lemon itha e larly a een in te lurer
part of the fiel! Some detail of the ubcutani ou a cular net
has l een lot by reluction and reproduction Note the value
CU in le long afhenou sein Female (al car eitli a
han rhifror troje (e fler no (011)

·123 AVTOVIC BASIS OF CIRCULATION uperficial and esen a few free bellied mucks ai o belong to this clas Gastrocnem A Anterior Tibial A Perancal gment of a muin uterial trunk Thest principal supply takes the form of a single ses sel or mall group of loralized ve el which usually cour e a considerable distance without and/or within the mu cle belly before pend ing in the intramu cular vascular pet Such mu cles are particularly vulnerable to interrup tion of their blood upply since for practical purpo e they are dependent on a principal upply it mut be understood however that although the principal supply is as described minor nutrients do enter the muscle belly else where along it length For example the prin cipal upply of the rectus monis and ga troc nemlius (fig 9) is derived from the lateral femoral circumflex and popliteal arteries te pertusely but both of the e mu cles al o re ceive transmuscular nutrients derived from the ſemoral and po teror tibial arteries re pec trely from the clinical viewpoint it is fortu nate that relatively few muscles Lelong to this class Outstanding examples are the biceps brachu in the upper limb (although on occasion it may a class 2 type of supply) rectus le mon biceps femoris and gastrocnemius in the lower limb Campbell and Pennefather mi takenly placed the gracılıs and vastus in termedius (crureus) within this (ategory but both are commonly upplied three or more sources di play Clogs 2 Fixed muscle sell, and sise persed supply Consi ts of tho e niu cies sluich have an ex RLSQUAdeen tensive fleshy attachment and hence a rela FC8 DSACR4X VADE FROX STOREO ANTEXT » DE tively fixed mu cle Lelly They are supplied by AY I TACT LFC autjes of separate or egmental arteries ) hich arise from a long egment of a main arterial N}ustrates the clone connection that ex Is Letween trunk Vlore often the e egmentals are de the blool upply of m cle and kn Semental ar dried from two or more main trunks and lor te les art hou act ing from the sar ou leg atterie large named or unnamed mu cular branches Vote the way in which they fo k into a muscular The characters tics of uch segmental have franch (11) o end in the il cutaneo s 1a cular ne Detail of the intramuscular branch (1) omiiled ir been mentioned al ose lot of the deeply ale of clarity ArTo s ind ate po it le tlood flow pared mu cles lieling to lus cla but many path Femal 18 years ·12+ PFRIVIRI CIRCULITION IN IIFALTII AND DISEASE Fic 9 MUSCULOGRANT OF GASTROCENTS AND SOLES (Tercers SCRAE) Note the ga trocnemic arterie de cending within the two fellies ol fa tro nemas (cla s 1 muscle) Forking egmental arteries derned from the deeply placed so tenor tiltal and peroneal arterie are exid nt along the lor ler ol oleus (clas 2 muude) Note the ana tomo es 1 queen the variou arterre within the mu (le and com; are the anterop terinr and lateral view Examples in the upper limb are the brachi alı tricep brachu superficial and deep fore arm fexors and exten ors in the lower limb the va ti artoriu oleus (fig 9) peronei and all exten ors and deep flexors of the leg The liam tring mu cles properly fall into this class since the perforating arteries of the pro ſunda fe mon aree entially major (gmentai The ilio p oas likewi e belongs here since it is upplied by egmentals derned from the ab dominal aorta and iliac femoral axis The sac ro pinali u supplied in a similar manner Class 3 Mired type Compri es tho e muscles winch exhibit fca tures of both the precedin, clases in that they ·125 ANATOMIC BASIS OF CIRCULATION possess a freely moving part as well as an ex superimposition of hadons inherent in flat tennie and relatively fixed part Such muscles film radiography Many ves el arrangements are upplied by one or more large muscular or patterns when een in the round or three arteries (named or unnamed) which cour e in dimensionally re olie them elies into part of on or beneath the freely moving part of the a simpler and more basic type of vascular pat muscle and also by numerous small arteries tern which actually varies little from my cle from multiple Ources which are distributed to to muscle In general the intramuscular vas the larger relatively fixed part cular pattern is surpri ingly constant although Most of the large trunk muscles such as the the way in which this va cular bed is led by the trapezius latismus dorss serratus anterior larger extramu cular ve sels varies Incom and pectorals (fig 10 11 2) fall within this pletely injected mu cle may produce purious class In each instance the position of the major patterns and such muscle is unsuited to micro nutrient can be anticipated beneath the mobile radiographic tudy and the a sessment of intra insertional part of the muscle The deltoid and mu cular vascular patterns spinati are similarly upplied receiving major Following experiments with vanous contrast nutrients from the anastomotic circlets about media it was found that radiopaque injectants the humeral and glenoid neck while their of small particle size (eg 25% Vicropaque* broader scapular attachments receive smaller sodium citrate solution with an average par nutrients from the periscapular arteries The ticle ize of 5 microns) warmed to just above pluteal muscles also fall within this class the body temperature (10 degrees C) could be disposition of the ves els being not unlike the introduced at physiologic pressures into fresh deltoid cadaveric or foetal material Human muscle The belly wall mustles when studied arteno arlerograms thus prepared showed a eres of graplucally may be regarded as a single mus fine anastomosing channels between the differ cle of this type for the fixed po tero lateral ent muscular arteries and an interesting me hi part is supplied by multiple small nutrients type of es el pattern not hitherto described while the mobile anterior part repre ented by The e point coupled with the finding (ee the rectus abdominis is supplied by the large below) that two types of blood flow path oc le sels of the epigastric chain cur through both human and animal muscle probably explain discouragin, resulta pre I\TRAMUSCUI AR ARTERIES viously obtained by earber workers who at Still le s has been written on the subject of tempted to ecure uniform and satisfactory in the intramu cular va cular patterns of man jection of mu cle It probably explains also although Blomfield made a radiographic study why inve tigators who used coarse injectants of a number of Jimb muscles following the in reported that the potential ana tomo es be jection of a barium collodion mixture into the tween the e ources of blood supply) are main levels 19 relatively few in number or that there was Reliance cannot be placed on one dimen practically complete absence of potential col ional radiography alone for certain of the e lateral channels Statements such as these patterns are apparent rather than real To served as criteria in the Camptell Pennefather study intramuscular ve sels in their entirely clasification (1919) and have not been chal and determine the es ential volume pattern of ſen,ed by sub equent workers a mu cle belly it is therefore essential to use Furthermore it was observed that when mus suitable contrast media in conjunction with cular arteries ruached a certain caliber they both stereoradiographic and steromicroradio appeared to retain a uniformity of size for graphie technics Such method remove the difficulties of interpretation occa joned by the Dama cy Ware Fngland ·121 PERIPHERAL CIRCULATION I HIFALTH AVD DISEASE FIC 9 MLSCL LOGR430 OF GASTROCHEVILS AND SOLELS (TRICEPS SURE) Note the ga trocnemi artenes de cending within the two lelles of patrocnemiu (cla s ! mu cle) Forking egmental arteries deri ed from the deeply placed ro terior til val and reroneal arterie are exid nt along the border of oleus (cla muscle) Note the ana tomo e bretupen the variou arterie within the mu cle an compare the antero-ro terior and lateral ven Fxample in the upper limb are the brachi ali irrep brachii uperficial and deep fore arm Nexors and exten ogs in the lower limb the va ti artoriu oleus (fig 9) peronei and all exten ors and deep flexors of the leg The ham tring mu cles properly fall into this da s since the perforating arteries of the pro funda femoris are essentially major egmental The alio p oas likews e belongs here since iti upplied by egmental derued from the ab dominal aorta and diac femoral axis The ac ro pinalis is upplied in a similar manner Class 3 Mixed type Compri es tho e mu rles whuch cxhubit fea tures of both the preceding cla es in that they ·127 ANATOMIC BASIS OF CIRCULATION Fic 11 VL CLLOGRAM OR GROSS ARTERIOCA 4M OF TRAPEZILS Anoth r good example of th gro s fa cular network or macrome h The upper end of the muscle is seen at the top left corner of the plate Th s part of the mu ele has leen di eute! Ivmi rral ograjlır metlot in the su ceeding plale namely fi 13 11 11 1 15 that normally exit between the e parts and its effect on the develop in, foetal plexus Inspeclion of a mu cle arlerogram such as that of the trapezius (fi: 11) shows that it 19 permeated by the coarse intramuscular vascu lar net or macrome l This me h is supplied ·120 PERITJIERAL CIRCULATION IN HEALTH AND DISEASE Fic 10 LATISSIBUS DORSI A good example of macromesh More that once a ye el has dropped to a certain caliber it tends to maintain that calit er over a relatively long di tance (2 to 3 cm or more) while helping to form the coar e intramu cular vascular net or macromesh quite long di tances and that this retention of joined and formed by any type of muscular umform caliber was due to the fact that they artery (eg egmental para axial transmu thien entered into the formation of an intra cular) In large flat bellied mu cles (sce fig mu cular vascular network composed of a ser 10) this mesh pattern was seen to be decidedly les of anastomosing arterioarterial arcades rectangular in outline whereas in long bellied The term macromesh was adopted for this muscles the mesh took the form of an elon Vascular network ince it can readily be seen gated rectangular pattern This system of ses in gross arteriograms of an entire muscle (figs sels it should be understood runs tridimension 10 11) The uniformity and marked length ally as can be readily een in stereoscopic arle of the contributing ana tomotic arcades be Tlo,rams The difference in shape of the mesh tween the various muscular arteries can al o as een in the trunk od limb mu cles is prob be readily seen This macromesh may be ably an expression of the growth differential

·129
ANATOMIC BISIS OF CIRCULATIO
Trt 1

·128 PERIPHERAL CIRCULATION IN NIEALTIL AND DISEASE ezius by small segmental arteries derned from the tissue such as muscle takes place intercostal arteries along the vertebral border Direct measurements made on certain mus of the muscle as well as from the descending cle arteriograms (e & latresimus dorst trap branch of the transier cervical artery which erralus anterior) revealed that this de cunds tran muscularly near its lateral angle coarser mesh was of the order of 1 cm to 2 cm Comparison foctal muscle arteriograms showed wide and 1 cm to 5 cm long although the size that this macromesh pattern in trapezius like of the me h naturally varied both within an in that of other muscles is established in foetal dividual mu cle and between different muscles life and is apparently a hereditary pattern as might be expected on the basis of muscle Enlargements of such muscle arteriograms volume alone It was noted that the size of the (fig 12) permit study of macromesh detail In macromesh was smaller in foetal than adult this plate it is possible to identify several seg muscles mental arteries and to observe the manner in Stereo copic arteriograms made of intact which they contribute to this coarse vascular members of the body as well as of excı ed network It will be seen that once an intramus and ı olated muscle groups and individual mus cular artery has dropped to a certain size cles provided definite proof of the participa tends to maintain a fairly uniform caliber over tion of the mu cular arteries in anastomotic a considerable distance and to continue as an arcades which could be traced in both the in anastomosing arcade without any marked alter fact body and exci ed mu clea Further con ation of caliber because it generally ana to firmation of the eri tenct and behavior this mo e with another branch of like caliber from la cular net was obtained by living microarte an adjacent segmental artery and so enters Tiography (fig 19) as will be mentioned into the formation of the network in the lower later right hand corner of the plate it will be noted The term macrome h wa adopted not only that tlus coarse vascular network or macromesh becau e the network was visible in our gross enclo es within it a yet finer vascular network muscle arteriograms (figs 10 11 and 2) but or micromesh of which mention will be made also because microarteriography next revealed later that within the coarse macromesh was a finer Study of the macromesh suggests that dur vascular network composed of the smallest ves ing growth it is subjected to a regional tension sels for which the term micromesh secmed since its meshes orientate them elses parallel mot suitable These terms were adopted be to the direction of both the muscle fibers and cause as will be seen they convey a mental strain This can be seen by examination and picture of the interrelationship between the comparıson of the direction of the macrome h structural pattern and the functional role of lying within the upper middle and lower parts these vessel, that is not possible to obtain with of the trapezius (fig 11) or again within the the limited connotation of the word anastomo pectoralis major or diaphragm (fig 2 16) When peaking of a net it is important This must occur during the period of histo to remember that the term me h is not only differentiation or that pha e during which the applicable (Web ter) to one of the paces en transformation of anatomically indifferent cell clo ed by the threads but al o to the thread into those characteri tic of a particular type of enclo ing uch space Hence on both ana SIS Fic 12 (see facing page) VICRORADIOGRAPHIC ENLARGEMEVT OF A REPRESENTATIVE TREA ( F TIIL MIDDLE THIRD OF I 4TIS DORS This shows the nature of loth the macromesh and the microme h which lae hittast it The microme h is well een in the bottom right quadrant Note the characteri tic tortuo ity of the small arteries and arteriale contributing to the mh an I their tendency to maintain their caliter ·131 AVATOVIC BASIS OF CIRCULATION ·130 I ENJI HERAL CIRCULITIOV IY JIEALTH AND DISEASE tomical and physiological grounds the term tangle seen in the previous plate The three me h scems desirable in view of the fact that macromesh se sels bounding the triangular We are dealing with a va cular pattern which area are now large and prominent and are ob forces consideration of the relation of tis ue viously arteries since they are more radiopaque (mu cle) volume to the ize of the enclosing and tortuous than the small sein, which ac nutrients as well as to the re ponse of blood company them within the triangle as el e ſlow paths to areas of t1 sue (mu cular) ac where can be een the finer vascular network tivity or inactivity and con equently to gradi or micromesh ents of metabolic requirement To determine the relationship between this Haung reached the limit of definition fine va cular network or micromesh and the apparently obtainable with standard radio capillary led still lugher microradiographic graphic equipment we next studied the e in enlargement was necesar) Thus the white tramu cular va cular patterns by microradio rectangle on the microradiograph (fig 11) graphic method Ex ected mu cles were sub contains part of a macrome h es el and an S duded into grid areas and multiple micro shaped va cular tortuosity that serve as orien radiograph, were taken covering the entire tation markers in the following plate (fig 15), area of a mu cle Becau e the field (1% to 5" which represents an enlargement of the ti ve cliam) obtained by microradiography was area within the white rectangle These markers greater than that obtained by the optical micro are prominent in the night half of this plate scope and becau e the mu cles so studied were while passing vertically across the field im opaque to light it will be under tood that this mediately beside them can be een the capillary mn thod provided an over all view of the intra Vessels wathun everal mu cie bundles De mu cular bed not po ble with the ordinary cending from the upper part of the plate to micro cope In addition various points were ward the e treaks can be een everal pre olved by re orting to tereomicroradiographic capillary arterioles Such ve els pring from Iechnics the microme h ves el more or le at right Microradio,raphs revealed within muscle a angles from the network as checked hy tereo will finter network compo ed of ana romosing microarteriography and pa s into the mesh arteriolar arcad, which we have termed the paces where they terminale in a leash like man microme h By way of illu trating the method ner to supply muscle bundles with capillaries u od for demon trating the e intramuscular Stereo copic studies resealed that the mac pattern the upper part of the trapezius (fig romesh and microme h patterns of mu cle 13) has been selected for microradiographic were not nece arily dependent upon or com study (the area indicated by a white rectan pleted by vessels coursing on the mu cle surface gle) Lying therein can be een three mall or in a plane parallel thereto but were usually Tessel of the macromesh which together form Inidimensional and joined by vessels deeply a triangle that will serve as an orientation placed within the mu cle or even upon the op marker in the next plate and will demarcate po ite surface Hence a me h may be een de the tis ue area di sected by this microradio cending vertically between the muscle bundles and yet another running parallel or longitudi The following plate (fig 14) is a microra nal to the muscle bundles Such a sa cular ar diographıc enlargement cosening the white rec rangement obuiou li permits the distribution graphic technic Fig 13 (see facing page) I PPER FD TRAPEZI SHOWINC MACROVEN The rectangular area at the top contain tl ee mali se el h h control ute to tem crome h These three ses el enclo e a triangular area wh h ha le n tu fie microrad ographi all to re 1eal the nature of the enclo et microme h a shown in the parts o plates (f. 11 lo)

·AVTOVIC BASIS OF CIRCULATION
133
Fic 14

·132 PFRIPHERAL CIRCULATION IN HEAITH AVD VISE ASF of blood to 177100 leds wilun the mu dle ing re sels which connect the e arteriolar and bellt venular netiorks with one another As will be The interrelationship of the macrome h and mentioned later the e connections take the micromesh is strikingly lustrated by the liu form of either ordinary capillaries (microcapil man diaphragm In the next plate (fig 16) at laries) or large macrocapillaries (preferential will be seen that the phrenic intercostal and channel, or a bridges) as shown in figure 23 other arteries supplying the diaphragm unite Venoi enous arcades here demonstrated have by means of arterio arterial arcades to form also been encountered in many other muscles an obvions macrome l pattern The tortuou of both the upper and lower limb lying in re arteries are accompanied on either side by se lation to the macrome h and microme h res nae comite luch form a similar but venous els network In the next plale (fig 17) wluch is Arning at Intervals from the arterioles form a microradiograph of one of the macromesh ing the micromesh and passing off to one side tissue spices' seen in the previous plate one or the other more or less at right angle can of the larger macronie h sese can be een on be seen mall tortuous branches best desig the right side of the field This prominent and nated a precapıllary arterioles (figs 18 19) tortuous artery serie to consey the cale of the Stereomicroarte riograms howed the e (fig other tructures imaged in this plate, since it 18) to end in a leash and gue ri e to the capil measured exactly 1 mm upon the contact me Jarse which pa s off and run parallel to one roradiograph in the criter of the plale is a another between and about the mu cle fibers beautıful example of the micromesh here en (figs 15 19) Such a precapıllary arteriole cloned Iny and communicating with the larger may supply capillaries to iko or three or more Sessel of the macrome h muscle bundles (hg 15) Cros connections On in pecting this field it will be seen that were ob eried to unite the capillaries about the ve sel forming the microme k maintain a the muscle fibers and thereby contribute to a uniform caliber for relatnely long distances capillary me h which een tereoscopically leg arteriolar length 5 mm to 15 mm ) helore actually takes the form of a longitudinally dis unting with a similar vessel and that there is a posed network both about and within cach double ret composed of arterial and senous bundle of fibers (figs 15 18) components An arteriole may be seen to be ARTITIOVFNOUS SHUNTS come continuous with an arteriole from an other source and thus contribute to the me h The existence of arteriosenous hunts within pattern or two parallel artenoles may be in muscle was sugge ted by certain phenomena terconnected by a transser ely running es el we had ob erved in animal experiments and of imilar or smaller caliber Thus a omewhat had been unable to explain There were for polygonal net composed of tortuous arterioles example the alteration of tained and un can be identified clo ely related to it hes a tained arcus within various mu cles during similar net formed by the nontortuous accom the tudy of the tran mu cular cour e of India panying venules The microme h is a double ink in luin, muscle or ag un the return of nct in the son c that the mesh paces are tra arterially colored treamlines of blood in the ser ed by the capillaries and minute connect outer or peripheral part of ome muscular F1c 14 (see li in pae) DETAJED IFK OF THE VIJ ROVESTI The entire ilute corre Fonds to the hute re tangle een in fig 13 the three sesweis forming the trsan le then that rectangle are here een greatly enlarged The te tangle mariel out on th plate 1 a enlarge to olxerse thr lation of the mi romesh to the capillary Id Ue the 5 Tape! tortun itt tatlan the rectangle for orientation in the best late (fig l5}

·133
AVTOVIC BASIS OF CIRCULATIOY
Fic 14

·134 PERIPIIFRAL CIRCULITION IN TEALTII AND DISFASE sens as ob ered while using the quartz rod transfert rice in mu cle this plac of a rabbit illuminating technic Such observations adductor mu cle clearly shows the strikingly prompted the development of technics that whute artı rolar arcades of the microme li and could demon trate both structural and func passing off from them at interal the pre tional endence of their existence Various capillary arterioles which in turn are seen to methods were used the study of cxcised and break up into a leash of capillary feeders The cleared human muscle following intra arterial capillaries are barely discermble as fine par and intravenous injection with different colors allel streaks pa sing vertically across the plate direct observation of the tran mu cular flow but it 18 (udent from the uniform opacity of of various injectants and contrast media in some of the venules uch as tho e in the lower fresh animal focal and adult human mu cle half of the picture that a transcapillary flow stereomicroradiography of human muscle so 1$ occurring injected and serial microarteriography show Uneven axial filling of the muscle rein is ing the transit of contrast media through the often observed and can lie een here For ex micromesh of living animal muscle (fig 19) ample in the upper right quadrant will be The illustrations of arterios enous bridges noted an unevenly filled venule which shows in animal and especially human skeletal muscle a dark central streak and an opaque peripheral (figs 20 21) presented here would appear to streamline This is due to the fact that a macro be the first published examples They do not capillary (preferential channel or a bridge) re emble the specialized structures described is di charging directly into it from an adjacent in the rabbit ear and human finger in that they arteriole thereby accounting for the peripheral do not show so called epithelial cells in their radiopacity of the senule (second from the wall upper right hand corner) In short this figure These experiments provided anatomical ex shows that radiopaque materjal may cross from dence of the existence of two pathways whereby the arterial to the senous side of the va cular blood might flow in its pas age from the ar net either via the capillaries or directly va a terial to the venous components of the micro macrocapillary (preferential channel) or both me hi not only in fresh foetal and adult human Colored microphotographs (fins 20 21) of material but also in the long animal Add: human muscle * cleared following intra arterial tional information was obtained by the fortui and intravenous injection of red and blue in tous opportunity to obserie the behavior of the jectants show that the e macrocapillaries (pre peripheral circulation and arteriovenous ſerential channels or a : bridges) which con brid,e, within lung human foetal muscle nect the arteriolar senular networks are not olurd month serratus anterior lati simus only larger than the adjacent microcapillaries dor i) for a period of two hours 5 or capillaries proper (fig 20) but are ap The next plate (fig 19) which represents parently des ord of any histological differentiat one of a eries of serial microarteriographs ing feature in their wall The direct manner in taken at rapid intertal following intra arterial which the arteriolar and venular sides of the Injection of a contra & medium (Thorocrast) micromesh are connected is very striking and provides visual evidence that there are two blood flow path or arterios enous routes of Titialis po terior Fic 15 (see facut, pige) MICROR 4PTOCRARI An enlargement of the rectangle from the çre sous plate (fig 11) howing the fines d ta! within the mi come h Note the horizontally di poud capilaries within everal mu cle lun les (here hovn vertaally) and in the upper left quadrant precapillary arterioles I a hing to the apullary bed

·ANATOMIC BASIS OF CIRCULATION
135
FIG 15
29

·136 I ERIPITERAL CIRCULATION IN JEALTII AND DISEASE in the following plate (fi, 21) the admixture its importance would appear to ment The of red and blue dye particles as readily seen volume of literature on blood pressure its es in another arterios enous shunt tablishment and estimation is truly enormous With regard to intramuscular veins, micro and yet curiously lacking in attention to many radiographic studies show that venules cor of the finer and subtle anatomical features of responding in general arrangement to the pre the human systemir circuit Again little in capulary arterioles recente a tuft of capillaries creat has been exhibited in the peripheral be from two or more mu cle bundles Venules haitor of contrast media in man other than to and veins are often dificult to see microradio depict the main arterial and venous channels graplurally hecau cthey hug the arterioles and and to dismu s the matter with the obeer ation arteries of the vascular nets and tend to fill im that arteriography grues no information as to fuerfectly and irregularly with contract me the tate of the arterioles dium Thus is apparently dur to the mode of While it is customary to regard the circula flow across the micromesh as described above tors sjatim as treelike such a comparison Contrary to general belief only the larger in does not accurately fit the facts for the pat tramuscular veins fute valies for injectants tern as Quiring also recognized is really have been ob ened to flow freely through the a last continuous nets ork of channel, of vary I enous networks within mu cle esen when in ing size Since basic functions are sub erved jected in a retrograde manner hy the capillanes and the vascular require ment of a tissue must determine the size of the Discussion local ve sels it should hardly be necesarı to It is difficult to know what mental picture empilasize what appears to he the fundamental the term vascular tree conjures up in the mind method of sascular development An embry of the average anatomiat phy iologist or clını onic capillary network precede the formation cran but it is probably ale to a sume that at of the larger vessels and the regularity of the can be little more than the oversimplified and recurrent and ana tomosing ven els forming rather diagrammatic schema on which se have the collateral and mesh pathways indicate all been raised a picture of a vascular trec that they too are so formed with the result that branching diminuendo until it terminales in a provision 18 made for both transporting lines eries of capillaries fcading to renule and and lor al or regional distributor sy tema vems or a system of arterie arteriole or Clinicians and anatomists have rerogni cd endarterioles capillaries and seins connected certain collateral pathways for years particu in seras as in an electrical circuit A modern larly tho e about the shoulder elbow hup and textbook of anatomy to states that the two tem knee but have tended to stress the e as a sec (ie, porta and pulmonary trunk) ondary of acce cory circulation and almo 1 imply break up into branches which again di entirely in relation to occlusive arterial dis side by repeated branchings the arteries be ease Various theories have been propounded come smaller as they approach the tis ue areas regarding their des clopment with a general they supply while the smalle branches or ar acceptance that they represent an enlargement terioles ultimately end in plexu es of se els of already exiting resuels but with les of mill caliber namely the capıllaries thought to their normal functional role The anatomical demon tration of the cir Few consider the regional patterns of even culation of thư blood by William Harvey the major arteries and sens in the human (1628) **as the tarting point of modern cir body either in terms of taste olume or direc culatory physiologt but strangely enough the tional Non Apart frosn the di butos and general plan of the called teme isterial pressure equalızıng sascular selworks illus trated here in muscle and kin the re are many tree and in particular the peripheral circula tson ha not been challenged to the degree that examples of larger anastomosing arterial and arterie

·ANITOVIC BASIS OF CIRCULATION
Fic 16 lt CILOGRAMS or UVAA DIAPHRAGV showing the
macrome formed ly Iran ke of the phrenic and inlette tal
arterie The arterial ca stenie appear fortu2 ble the ac
rom »n. 1339 asr more direct The my cular part of the
siglt eurala 1, Tech ecte ! mr orada raz hically in the
heil air fhg 1)
LET

·138 PERIPHER IL CIRCULATIOV IN HEILTII AND DISEASE Senous arcades in the human body which must becau e of the anatomical evidence of the mac be regarded as forming the coarsest type of romesh and micromesh patterns second be distributor and pressure equalızıng circuit cause of microradiograpbic demonstration that When the large anastomosing arches or ar the arteriolar components are longer than has terio arterial and veno venous arcades of the been generally realized third because these trunk upper and lower limb are placed in mesh patterns must be regarded as local tissue juxtaposition (fig 22) it hecomes apparent reservoirs as well as distributor and pressure that they must be regarded as similar to the equalızıng mechanisms and fourth because sinaller arterial und arteriolar arcades evident of the existence of arteriovenous shunts and in the microme h and micromesh The closed dual blood flow paths (figs 19 20 21) loop circuits formed by the forearm arteries Because blood escapes from the arterial res and palmar arches les arteries and plantar ervoir in a continuous manner throughout the arche intercostal arteries and epiga tric cardiac cycle the suppo ed conversion from chain may serve as allustrahons For apart intermittent to continuous flow has been gen from supplying and draining the large tissue erally ascribed to the recoil of cla lic arteries mas es or islands enclosed within their loops the volume of flow being a cribed to the rela the e arcade mu l represent a coar e me hed tive magnitude of arterial recoil arteriolar re Tran port ay lem that provides pressure equal sistance and cardiac output But as liggers izing di tributing and flou mechanisms has emphasized in his writing on the circula uited to regional requirement Their behavior tory dynamics of hypertension to mphſy it would seem cannot be properly explained hemodynamic anals es small arteries and ar by a purely lintar approach to the pressure terioles have generally been treated a though gradient of the sy temic circut and over im they branched dichotomously into capillarie plifications of Poiseuilles nonbiological law resistance being computed from the re pective nor bc adequately registered by existing pres lengths and diameter of successive linear ure and flow metery Radiological serio egments Furthermore such a scheme he grapluc lcclinic u ing image amplifying ap adds fails to take cognizance of large and paratus and various pharmacological agents small arteriovenou shunts would appear to offer more likelihood of elu Resistance to blood flow occurs tlıroughout cidating tlieır bu havior the so called arterial tree but in the concept of It has been customary when considering the peripheral resistance it is the minute vessels development of the arterial pres ure to regard (10 arterioles and capillaries) that have the larger ve sels as reservoirs or pressure been regarded as constituting the chief areas tanks guarded centrally by the heart valves of peripheral re istance The accompanying and restricted peripherally by the arterioles diagram (fig 23) however which is based on The explanation however for the pressure dif the modes of blood transit ob crved in the ferences in the various anatomical divisions microme h of losing animal mu cle and avail of the sy temic circut as traditionally repre able pathwave di covered in human mu cle ented would appear to require revision firt illu trates certain features of the peripheral Fic 17 (see facing pa e) MICRORADIOCR4PH or HUTAN DIAPIIRAGM This hows a beautiful example of micromesh The fortuou riole are een to enclose poly gonal areas and form an intramu ular va cular net over which is dra n a senous net formed I, nontortuous renules Capıllaries and macrocapıllaries (preferential channel ) connect these arteriolar and venular networks (figs 19 20 and "1) The calıber of the mallest ses els may be gauged from the large tortuous artery at the ri_ht whi h measur 11 mm on the conta t micro radiograph it al o erses to indicate the marked len_th of the arterioles

·AYATOVIC BISIS OF CIRCULATION
139
FIC 17

·140 I ERIPHER IL CIRCULATIO IV IIEALTH AND DISEASE Fic 18 STEREO311CROR 4DIOCRAPHS OF LAT1931US DORSI The lower pair how the ana tomo ing arteriolar arcade hich make up the micromesh an! I recapillary arteriole ra ing off more or less af rtpht angles into the me h pace The urrer pair how a large segmental artery flanhed by venae comites Beneath the eye els are seen pre capillary arteriole ending in a lea h about the phantoms of the mu cle bundle Microme h ana tomo es (top left corner) occur between uperficial ani deep lesel These demon trate how this technic overcomes difficultie of interpretation occa toned ly sa cular superimpo ition Ties with pocket tereo cope ler Zei s No 6001) mesh patterns that call for a reusion of tradı blood flow in relation to changing cardiac out tional ideas regarding the systemic circuit put mu t be considered again t the exi tence of Thus the dampening of intermittent flow such mesh patterns in the major issues as mus maintenance of local blood flow conditions cle and kin (figs 21 25) and alternale path and accommodators or release mechanisms ways for the pas age of blood as indicated by which augnient or reduce the rate of peripheral two types of arteriovenous communication Fic 19 ( ec la ng page) Lunch ABRIT {ODLCTOR III cle Serial microradiograph taken after intra arterial injection of Thorotrat Mote the trikingly white arteriolar arrades of the microme h and al o te pre apıllary a tertole wh ch lead into the me 1 paces an! gke ne to capillarte {api re are jut d scernible a 6 e parallel treaks acro $ the field in the upper reht qua Irant the u evenly flled enule looking a dark center and white peripheral treamline is fue ir a ma ro apıllary (preferential channel) di charging directly into it from an adja ent arteriole look to the right of the loner end of the elon gated white artifact for this channel (bet viened from night de) ·141 AVATOMIC BLSIS OF CIRCULATION ·142 PERIPHERAL CIRCULATIOY IN HEALTH AND DISEASE Examples of Arterial and Venous Arches in the Human Body Fic 22 Gross MESHLIKE ARTERIAL AVD VEVOUS AVASTOYOTIC ARCADES FVIDENT IN THE MAJOR FSSEIS OF ALL REGIONS TIE IIUMAN BODY (SAUNDERS) many of As may be seen fig 23) the arterial and above apparently serve to hort circuit or lry venous nets whether large or small may be pass the low level or nutritivc path according considered as peripheral reservoirs (PA PV) to metabolic requirement This also probably which apparently have a pressure threshold explains why the sa omotor center can regu (P1 P2) Using an area of the micromesh as late the ba al flow in muscle and yet cannot in a module or unit of comparison it is evident Nuence the circulatory changes during actauty that the mode of transit from the arteriolar to Preci e hemodynamic deductions concern the venular net may occur via ordinary capil ing the peripheral circulation of man lave lary ſlow (A) wa a macrocapillary (B) or proved delicult for various reason more precipitately by a direct arterios e nous which are obvious The physical effects of connection (C) The mode of Iran it adopted vascular branching varying caliber of the ar seems to depend partly on local metaboli m turie and changing ui cosity of the blood are and partly on chemical and hormonal regula among tho e commonly cited but it should be tion of the mesh in toto vhile a nerious con eudent from the pictures presented here that trol whether of a local reflix and/or central the concept of peripheral pre sure and hence ti pe would appear to be provided for by the the dynamics of either hypertensjon or hypo nature of the neri e supply of the mesh Since tension have be based on an inadequate pic the e microarteriographic studies have shown ture of the arterial tree and the volume pattern that there are two low paths in the micromesh of the blood ve els uithun ti we such as mus Ne mu t think in lerms of a high level or anas cle Microurtt riograplıy has made it po able tomotic and a low level or nutritive circula not only to demon tratt and to measure these tion The arteriovenous connections mentioned ses el thus providing valuable information ·3 FIG 90 ARTERIOSENOLS BRIDGE BY HUMAY CALF MUSCLE Cleared sections from brala po terior following intra arterial and antra senous injection of Ted and bluc latex respect ely Note the red macrocaplary preferential channel) discharging directly in the venular net it is of larger caliber than the adjacent ordinary capillasses (Koda chrome) FIG 21 AKTERIOSENOS BaiDCE IN HE CALF MILSCLE Sate that al Baked by shree senal and passing from the srleriole to the central venule a la BAVI dge showing an unmi tekesble admature of dye granules (hodochrome)

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·ANATOMIC BASIS OF CIRCULATIOY 143 PA Borc Pressure conditions in the Micromesh Arterial net Venous net Mode of transitin Micromesh Traditional concept ReSounders Fic 23 MODE OF ARTERIOLAR VEVLLAR TR4191T THIROL CH THE VICRONESI It is sugg ted that these vascular n ts serve as I tributor and presure equalızıng mechan ms which apparently pou 9 a pre ute thr hold that use one or other of the I lood tran il pathways shown for hemodynamic or circulatory calculations application General 1a cular di eases such but also to ob erve the behavior of micro copic as hypertension shock burna etc mu t have blood se els in vivo aound anatomico phy hological ba is of the The imilarity betseen intramu cular cu empirical approach is to give way to knowl taneou and vi ceral va cular patterns (eg edgeable treatment The anatomy of the pe stomach and gut) forces one to regard the ripheral circulation of man has not been greatly me l as a ba ic va cular characteri tic who e extended since the time of Illiam Harvey control 13 peripheral in the ene that it is de nor has sufficient attention been paid to va cu termined by the activity of the ti ve cell lar areas intermediate betneen the gro er and The importance of the blood supply of indi the micro copic ses els vidual mu cles is self evident and obvious in its

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·ATOUIC BASIS OF CIRCLLITIO 143 hic 24 (see page IH) CL14 VEOL ARTERIULRAY OF SAIS FRUY THIGH Th , plate hon that the al utaneou arular net I lewk con 1 t of a macro- and micromewh pattern Compare with fig 12 but make allowance for difference in magnification The lin of every body region imilar and the Rin \a-cular me h very tuiking when viened tereo-copi cally Vale aged 7 years Fic 25 (see pige 144) SCBOLTAVOL GRO Tavol \ETWORK OF 4 Lung CLBJECT 4 SHORT BY INFRARED PHOT WRAPHY Pro ide ith ubjects are not too fat the technic readur demon trates uch mesh pattern in the kin of both the trunk and limb of healthy children and adult It rescal the mesh pattern as a fundam ntal feature of the fenpheral circulation of li ing man Compare with fr 2+ Healthy male age! 6 years References — Part V 12 EDWARD E. A The anatomic bat for chaemia localized to certain mu cle of the loner lim! Surg, ner & 01 9 R 1933 13 GRAS Descriptive a d Applied Anatomy Ed 30 London Longman 1919 14 Vorris Human Anatomy Philadelphia Blak 1 ton 1919 I CLARX W E. LEG AND BLONFIELD L. B The eff vency of intramu cular ana tomoses with olmeration on the regeneration of de Vacularize mu-cle J Anat "als 1975 SPALTEHOLZ W De leth lung der Blutge ſame im Vu hel Leipzig Hirzel 1803 3 BURTON AC. In Cuba Sympo rum on De ripheral Circulation in Van Lolon Church all 1951 4 LAWRENCE, J 4 AND SAC DER R L DECH Microra lographte tudies of the effect of vari ous pharmacolog al arent on the vessel within living mu cle and kin of animal (In p eparation) 5 SAL VERS PL DECH Olnersations on the per pheral ci culation and arterio enou bridge in a li ng human fortu (in po 6 LAWRENCE JA AND SAUNDER RL. DEC II Ved al and dental app! cat a of tereomicroradiography (In pres) 7 SALMO 1 Arteres de mucles de membr et du tro Pan Va on & Ce 1933 8 CAMPELL, J AND PEYVEFATHER GY An in ve tigation into the blood upply of muscle with secial referen e to war ure > Lan et 191 1919 9 P WER Ga gangrene with pe al rel ee ce to sacuları ation of murBut, I J 1606 1915 13 PIER OL Human Anatomy E19 Philadelphia Lappincott 1930 16 CC YVINCHAN Textbook of Anatomy Ed 9 O ford Oxford Uni erett Ire 191 1" CLARK WE LEC The tt ur of the Human B dy FI - Otford Clarendon 1946 18 ADACHE B Da Arterien s tem der Japaner Aroto lerlag haverl-Jap Unn 19 19 B103F1ELD LB Intamu ular sunlar pat fern in man Po Pos Soc Veu 33 61 1945 PODARD DE V BROWD AND PEAR IN GM Drease of Muscle New York Hoe ber 1933 IBRA 11 JC Teuro-ascular Ilula of Limb un le Edınlu gh Li ing ton 195) SIL DER PL. DEC II Tle Intramu Ular a cular pattern of the foetu tion) (In epara 3 HARVEY T Et reitto Ipat ma d Votu Cord et sa un in In malı! Frank furt 16.8 10 W211 E BERC 4 Die Arten n orgung von Vuk In un ihan Zt-chrit f orthro] h 11 31' 1907 11 Niche 1 haem necrol of the an 10 Ilal m les due to fatigu J Bone & Jos 30B X1 191 1 QLIRING DI Collateral Circulation Phil delphia Les & Felger 1919 23 ICCEK C) Ci culatory d names Jew York Crun & Stratton 1937

·141
PERIPHER IL CIRCULATION I JEALTH AND DISEASF
FIG 24
FIC 23

·I VDEX 117 in martomesh formation 1 0 137 metacarpa) 2 metatarsal 4 obliterative di ease 18 59 and vasodilator stimulus 60 oh truction 78 patholo y 18 occlu ion 16 collateral circulation after 19 restoration of primary channels 84 85 para avial 196 ratterns 117 r toneal 124 phreni and intercostal 137 pipestem 46 plantar 34 popliteal 3 radial 5 reservoir 138 segmental 117 126 in netwrks 120 121 size and structure 45 11 tarsal + tibial anterior 3 po terior 34 1.31 transition to capillanes 6 ulnar 2 vasodilator impulses to 10 11 and venous ana tomotic arcad s 112 volar 2 Arthritis defo mities due to 65 Theumatoid 52 dfferentiation 66 4 phyxia reticularis 53 Aspiration 14 Athma hronchial 92 Atheromato 19 artery condition in 46 47 and diabetes mellitus 101 Atherosclerosis 46 48 and thromboti occlu ton 42 43 At ophy hon 69 mu cular 16 of sut cutaneous to sue 16 Auscultation 18 Autonomi nervous syst m di turtane 59 and endocrin hormon 63 Irvation of va cular tree 10 pa asympath tu 11 sympatheti 10 Ayerza s d spa e 19 anglionic 89 93 nerve 9193 and reflex va omotor te ne 6 ympathectomy for 93 94 in Yasospastic conditions 93 Blood coagulation 6 and anticoagulant Se Antt vagulants and heparin 95 intravas ular 45 reduction respon es 65 and ve ous draina € 95 99 dyscra las anticoagulants ontrain licated 97 Te pon s to 65 Bloo} flow alteration in 41 66 arterial from aris 1.0 di ea es of 16 20 intrinsi I orders 1251 tet for 701 77 30 and arterioven us fi tula 41 capillary 6 12 and cardiac output 256 61 110 cerebral and autonomie vasomotor control 13 and va cular disea e 58 101 102 circulating volume 26 collateral or secondary development 7781 enhancement of 26 91 in of literat e arteriosclerosis 47 in ve outbromlos 99 ro onary and tachycardia 92 evaluati n 15 33 of mu cle 32 33 113 14 to extremities 13 frugs for effects on 8.9. an I heat lo49 27 a I heart di ea e 42 10. m nute 12 a d card ar output 3? d sea e of 18 19 di turl ances due t d formities 65 100 extrava ations 18 humoral factors in 13 tric di orde $ 46 55 56 in mucou m ml rane 65 and P tre n65 tet for 21 23 aried respo es to same stimulus 17 paths th ough mu cle 125 131 13A 140 rate 15 tes tance 138 143 respon e to Yasodilator stimulus 59-62 re toration 87 routine measures for 86 hifts in a cular beds 33 short circu ting 10 skin 32 33 venous color changes 19 disea es of 19 20 intrins c d sorders 41 45 51-55 te ts for 33 Blood re els in acute infe tions 46 constriction and adrenal n 61 graſte 85 Benzodiovan 89 Biopsy for polyarteritis no los 59 for und ruskin nodul s I/ Blanching 16-17 and postural chang s 20 Raynauds dease s Blebs 7 Bl ters 17 Blo kade 94 103 deep drugs for 89 99 side effect 9 dr nergc 89.9 nous 53 ·Inder \ldomen 3 14 Acetylcholine 12 13 Actoryanosis 53 Icrosclerosis 53 Adrenal cortex 63 Adrenal medulla 63 Adrenaline relea e by pain 14 and 12 ocon triction 63 Albumin and coagulatsen 45 Anıputation for gangrene 102 10, in minute circulation 100 Analgesics 99 Ana tomosis arterial 1 121 segmental 120 arterial arteriolar 126 138 acteriolar 130 arteriovenous 6 142 subcutaneous 57 in collateral and mesh pathways 136 in formation of macrome h 116 121132 of microme h 129 133 112 intramuscular 16 and gunshot wounds 115 Intrasenous 138 Anemia hemolytic 41 hemorrhagic causes 56 hyperetrculation in 61 in Kaross Karcoma 58 in lupu erythematosu 52 Aneurysm arteria) 18 of cerebral vesel 58 in polyarteritis nodosa 51 Anger 14 Angutts 66 Angina 15 Angioblasts 56 Ingrocardiography 26 Angioma 19 pider 56 Ingioneurosis 63 Ansolysen 84 91 Inthrax 43 Intibotics and fungal growth at leron 101 in thrombophleline 95 of uperficial seine 99 In ulceration management 103 Anticoagulants antagonit 98 in arterial occlusion 101 ant cardiova cular dises e 98 in cerebrovascular disease 102 contraindications for usage 97 in senous drainage impairm nt 9507 Antihistamine 102 Aosta abdominal 3 a Idle thromb of 85 wall structure 5 Aortography 21 Apresoline 90 Arcus senilis 50 Arlidine 90 Arm See Extremity Arrhythmia 92 Arterides 101 Arteriectomy 92 with Yessel grafting 85 Arteriography in microcirculatory studies 115 117 120 127 radiopaque substances for 21 Arteriole anastomosing arcades 110 and artery in macromesh 116 un atleriosclero is 46-48 formation 2 transition to capillartes 4 precapillary 5 In micromesh 135 140 size and structure 5 Faso Jator impul es to 10 11 venulas transs throueh meromesh 143 Arteriolitis 47 Artertolonecrosis 47 Arteriosclerosis 46-48 cerebral 50 58 cutaneous sugillattons 17 and diabetes mellitus 101 obliteratuse 4.48 50 treatment of 101 respon es to warming in 59 ulceration due to 103 Arteritis primary acute 43 in strated muscle 52 types 43 44 Arteritis obliterans 48 Artery auilary 1 316 I rachial 13 calcification 50 caliber 45 channels to extremities 1 478 in luced channes 86 constriction and cardsac output 32 release of 81 85 digital 24 dorsal 34 epigastric 4 extramuscular 115 femoral 3 123 segmental forks 12° gooseneck 46 hyrogastric 3 olac 3 4 insufficiency and lanching 16 tests for intramuscular 120 125 139 involvement in arterit 43 in arterioienous fistula 11 schiadis BO 116 ·INDEX 117 in macromesh formation 120-137 Mitacarpal 2 metatarsa? 4 obliteralive disease 19 59 and ya odwator smulus 60 o'rtruction 18 pathology 18 Occlusion 16 collateral circulation aller 9 re toration of primary channels 818 fara ayal 196 Palletne 117 peroneal 12 phrenic and interco cal 137 Pipestem 46 plantat 34 roplitea) 3 radial 5 Teseror 138 >gmental 117 126 in networks 1 121 size and structure 45 11 tarsal 4 tibial antctor 3 pa terror 3 4 1.324 transition to capillaries 6 ulnar 2 va od:lator impul ex to 10 11 and venous anastomotic arcades 112 volar 2 Arthriti deformities due to 65 Theumatoid 59 differentiation 66 A phyria reticulari 53 A piration 11 A ihma bronchial 92 Atheromatosis atlery condition in 41 47 and diabetes melling 101 Athero4 lerosis 46 18 and thrombotic occluson 42 13 Atrophy hone 67 mu cular 16 ol sub utaneous t1 sue 16 Ax culat on 18 Autonomic nervous system I turbanre 59 and ep Jo ne horm ne 63 In ervation nf 1&scular tree 10 para ympathette 11 sympathet 10 Ayerza s disea • 49 ganglionic 8993 nerve 9 93 and refer sa omotor rexy ones to sympathectomy for 93 91 In saso pastic conditions 93 3}ood coagulation 26 and anticoagulants fee Antcroagulant, and heparin 95 iniraya ruar 15 reluction re ponses 65 and senous drainage 95 99 dysera sas anticoagulants contraindicate 9. responses to 65 Blood How alterations in 41 66 arterial from art 1 di eases of 16 22 antrin vcd nrders 4251 te is for 20.21 27 30 an! arteriovenous fistula 41 capillary 6 12 and card ac output 20 6 61 110 cerebral and autonomie vasom tot control 13 and vascular disea e 58 101 10 circulating volume 6 collateral or secon lary development 7787 enhanc ment of 86-91 on olliterative arterioscleros19 47 in venous thrombose 98 coronary and tachycardia 99 evaluation 1533 of my le 31 33 113 11. to extremities 13 drugs for effects on 879 and heat low 27 an!h art d esse 42 10. 12 e!שתנות Benzodiovane 89 Biop y for rols arteritis not a 5. for under skyt nodul 17 Blan hing 16-17 anl postural change 20 in Raynaud, disease 5? Bleb 7 ili sters 1 Blockade adren e 88 9 91 103 deep senou 54 drugs for 889 Me flrcs 9 and casd ac suit 32 Heases of 18-19 fisturbances due in lelo mlin 65 100 extrava atong 18 humoral facto in 13 intrin ic disorders 46 55 56 mu ous memi rane 65 and Pitre in 65 testy for 21 23 varied respon eu to same stimulu 77 paths through mud 125 131 138 110 rates 15 Te i tance 138 113 Te ponse to a odilator stimulus 59-6? restoration 8% routine measites for 86 shifts in vas ular led 33 "short circuiting" 10 kin 32 33 enous color cha pes 19 disea es of 19 intrin ord N 415 5155 Inele for 23 Blood vessels in arule infections 46 constri 1 on and adrenalin 61 grafting 85 ·148 INDEX of literation 9P pooling 1" 32 respon es to timul: 10-11 ze development 80 splanchnic and exercke 14 uterine after parturion 49 va oronstrictor impulses to 10 wall injors 45 Blu hing 14 87.80 Bone atrophy due to sa ospasm 62 forearm 2 formation in atherosclero is 47 le con 58 marrow depres on 95 IT cells 52 Brain lesions 58 metaboli m 101 and migrating hiel 111 55 "paradoxical emlalım to 41 retinal arteries in arteriosclerosi 18 va omotor centers in 10 Broche Trendelenberg test 21 Buerger > exercise 86 Burning 16 18 Burns 1" 46 Butazolidine 93 Cardiovascular s tem and adrenergic blocha le 92 and arteriovenous fi tula 51 Cau algia 59 Cells contraction by elect timulus 5 endothelial 4-6 in vascular tumors 57 LF 52 lymphocytoid 57 58 mesenchymal 80-81 red 7 Rouget. 5 Rouge Veyes 6 smooth mule 11 Central nervou sy tein and adrenergic I lockade 92 va-odilator impul.py from 11 Chtblaun 54 Chorda tympani 11 Circulus senil 50 Cirrhosis of er 5h Claudication di tance and time to 20 27 intermittent and arterial in ufficiency lo-16 in obliteratsse arteriosclero 47 in selection for tmpathectomy 93 Cold injury 46 Coldnes and acroryangil 53 in arteriosclerosi 17 in occlu re di or lers 16 Colla en dira e 51 100) Connective tue 45 legeneration $6 in endarteriti 19 and mu cular ratio in arter 11 Cooling 11 See also Colinas Corti Osteroid 101 Coumarin 95 96 (ryoglobulus 16 umopyran 9 Luty marmorata 53 (yano 119 Citoplam 6-10 Calano 1 46 Calorimetrs ? Capillaries arterial and enou 5 11 and arterioles tran ition 5 caliber 6 collape and organ function 6 in extremities + heart hemangioma 56 intermediate type 10 of larger va cular channel 80 loop10 fiant 52 in ul rapillary venous plern 19 Wire 52 in ma ro- and mi rome h races 132 mi rour ops 2 networks meshes of 5 permeal ality 63 100 pre ure 22 ulation 11 Tess on 22 in shock 6+ ize and trurture 1-6 totic injury 43 46 and type of telangt eta ts 56 1asodilator impulses to 10-11 6 wall damage to 18 16 100 formation 7 within mu ciel undles 131 Carbon diotide accumulation 8 Cardiac output and arterial con triction 32 and arterios enous fi tula 41 102 circulatory respons to -26 61 140 during sleep 11 an! pooling of blood 32 Cardiosa cular disease and anticoagulant 98 Dermatomyositi 52 Dermographia 65 Diabetes mellitu 50 and arteriosclero 1 49 and sa cular drueave therap: 102 103 Dibenamine 88 derisalt es 91 D Benzyline 91 9. Di oumarol 9 Diethylaminoethanol 81 XP 91 Digital 98 102 Diparin 9 Dspbiberia 43 Drainage imatrment 1 11 4 manaf ment 92-99 nous 2.4 omsli ating di furtance ul papıllars plexuses 10 and aomotion 12 Du tu arterio 49 en Ds trojhs 58-59 62 ·INDEX 119 Fati ue 16 tue test 99 Fear 14 Fever due to em olism 45 th rap) 81 Filers adren rgil va olllator 12 13 choline gk 12 13 colla enou 11 formation of pleru 10-11 involuntary mu cle 4 medullated motor 10 nerie 5 preganghonic 10 reticular 5 omatic 10 Vasocon tri tor 101. asodilator 10 12 13 Fibrillation auri ular 92 Fil n oid dt ease 51 Fi tula arterio enou acquired 44 50-52 asymmetry due to 16 congenital 51 manacement 102 pulation in 18 Flu hing 14 Fo amen o al 45 Frostbite 46 53 Ecolid 90 Edema in arteriovenous fi tula 51 in varicose or tatt ulcers 0 and venous o truction 19 Elephantia 13 16 19 malignant 100 Embolectomy 85 Embolim diagnosis 18 pulmonary 45 98 anticoa rulants for 95 ceptı 98 anticoa ulant contraindication 9 Emotions and blanchine 1, 6 Ena th mata 46 Endarteriti acute 43 and endophlel 1 42 fhrona 4 ollut rative 49 productie 47 treatment 101 Endocrine di truban pe 63 61 Endophlebiti 48 Endoth lium 5-6 Enzymes in gan, ene p e ention 10 103 Epiphy 51 Ergog aphy 29 Ergotamin 49 90 Erys pela 43 Erythema ab igne 51 nod um 16 18 pernio 51 Erythermal ca 18 53 Erythralgia 9: Exanth mata 46 Esercie and Intermittent claudication 15 in routine 86 and secondary I lood supply 101 test 20 va omotor re po ses to 14 Extremity a trial channels to 1-48 induced changes 86 bicep bra hu 123 blood flow 15-3 118 10 collateral 81 d sus 16 20 embol min 45 enlarg ment 16 51 gange p pre ention 102 103 hyd ostatc pres ure 1 mu cles 12 120 121 oblit ratiy dae 59 pigme tation 51 po iti nin treattnet 9 re pon es n to d ac output 3 Gbbon Landis provedure 81 operations a dt uma 7 $ face temperature 8 smp th ctomized 69 dra nag 3 moto nrses 10-11 Cang ene amputation for 102 arterial involvement 43 due to arte jo e ou fi tula 51 and fo tl te 53 and hemoglobinuria 66 juvenile type 48 mont 17 Treve ton 102 103 spontaneous 48 mm thical 62 Cangl on blo kade 89 13 Ga tr ntet al tat and adre e gic ble hade 9 ad ant coagulant 9 Cenito-u 10 ry tra t 9- Gull on L nd prore lure 31 59 6? in arterial spam 84 th rapeutic aspi cation 86 Clom ruloneph it 59 Glomus dru,s for effect on areas 97 89 tumo 57 100 alt 83 s de ea 63 elation ad pat Hair abnormalities 16 51 H art and arteriovenous fi tula 48 51 arterosclerotic 50 funct on 80 | ions 52 ani i grata & chi litis 55 rate 11 42 rheumatic dt asen Heart failure 11 D conge-tise and Flood flow 41 eteretse in 86 and pulmonary emboli m 4 ·150 INDEX Influenza 13 15 Intestine visceral le long 58 Intima molsenient 47 proliferation 19 tripping 85 thickening 47 Irradiation 100 Kaposi s sarcoma 57 58 100 kidney arteriolonecrosi 47 di ea e and anticoagulante 97 lessons in polyarteritis 52 hich test 20 venous return in 19 and cyanosis 17 Hecht Dalldorfs test 92 Hemagglutination 66 Hemangioendothelioma 57 100 Hemangiomas 56 57 100 Hemangiopericytoma 57 100 Hemangiosarcoma 57 100 Hemoclobinuria 66 Hemorrhage and anticoagulant therapy 91 due to hemangiosarcoma 57 of hereditary telan,jectasias 56 due to hapogus sarcoma 56 Purpuric 13 in Rendt Osler s disea e 100 shock 61 and surface va oron triction 30 and vasomotor tone 58 Heparin 26 9 llevamethonium 81 99 91 Hexameton 89 Hi tamine 87 91 flare te 22 Ilomans sign 45 Torners syndrome 93 Hydergine 90 Hydrazinophthalazine (6 Hygroma 57 Ilypercirculation 63 61 Ilyperemia 21 Ils perhedrose 18 Hyperplasia 47 Hypertension and cerebral circulation 58 complicating 50 fever therapy 87 and peripheral presure 112 111 due to phaeochromocytoma 63 pulmonary 49 and renal arteriolonecro 1 47 and va cular disea e management 101 Ilyperthyroidi m 61 Hypervascularization 65 Hypocirculation 63 Hypoplasta 51 IIypotension and collateral blood flo: PO and drugs for vasodilatation 89 91 po tural 92 and quaternary amines 81 85 Hypothalamus involvement 58 a omotor centers 10 Flypothermia 101 eriches syndrome 15 83 Isjons cerel ral 58 in Kapo is arcoma 57 58 peripheral nerve 59 in polyarteriti 57 of pinal cord 58 59 in telangiectasa 56 Teukemia 65 I eukocytose 13 I ewiss Triple lespon e tet 27-3 La man Sachs syndrome 52 Lipation 98 100 Ilvedo reticuları 53 Liser Garcho 1 56 Cinction impairment 97 neural mechanı m of led 13 veral le rong 58 Lumen obliteration 41 in response to tumul 11 12 I ung eml olic epi odes 45 98 anticoagulant in 95 failure and everci e 86 infarction doe to infected clot 97 and migrating phlebita 55 tul erculo 49 visceral le ion 58 I uptus erythemato us 52 66 Lymph gland enlargement 15 no le le ton 58 ta 16 19 lymphangioma 57 100 lymphangio arcoma 57 100 Lymphedema 19 99 Il lar 88 P9 do age requirement 91 92 Immer ion foot 46 55 Infection of blood clot 98 gonococcal 43 inflammation due to 41 thromlosis due to 98 and venous wall damage 45 Inflammation and foralized warmth 18 in superficral venous channel 98 ani vascular disea e states 42 66 Vacrome h arterial and arteriolar ar ades 138 intramu ular 111 116 bt eps bra his ma le of deltold mu cle 118 119 ga tror nemtus 121 latı simus dorsi 126 128 pattern 138 pe toralis major 116 profunda femari 19 8177 178 cu 121 1 apezius 12 131 ·INDEX 351 median 1 yelvic 11 po terior spinal root 13 ulnar 2 agas 11 Yasamatos 1913 Neuritis 62 Pearoa 53 63 He trs lammeu 56 Ai oladons Branham 41 Nicotinic acid BX 100 Nitroglycerige 88 Nora lrersal pe 63 umbres 16 Patrition 1° 56 Va rophages S Malarta 43 Varcomar 97 la tarditis 5 Mazo extralum sal truper 99 Vel orylan ne hydrochlon le 999) Metaboli testiral 58 an vasomotion 1! 13 Vethum ?) V rroangiopathy thronlot 141 Vicroarter Agraphy 115-113 defined 118 130 Vi rome ha artenal arterzolar 138) 9 artenolar venular 143 capillary 133 135 Laphragin 139 lats imus dorst 199 patiron 139 V roy deace 99 Vitral vahe sten 18 45 67 Henckebergs reso 16-17 Honotate 99 Via fc adductor 142 to end 10 223 Band upply 113 115 Ira halı 390 cla hcation 190-15 8 lord 118 119 125 and elast e tue tato 11 and tramu culat arteries 115 in e tremitses 12 171 filer 5 Rastro Gemi 123 12 gluteal 125 lall us dorsal 10 ma romes! and come h patterns merrelationship 132 trid men sona) 330 Ta furat 114 116 118 nel to girdle 3 profunda ferros 3 2 1 rectus femoris 123 letal abnormalities 65 66 arterial d inbutron to 11a Iloid sur ply 113 14S neural mechanism 13 new classification 1 11.5 stycoth arter olar 5 sofeus 12! fenatt 195 talis anterot 31 tissue 1 trapezius 231 trunk, 118-1990 225 Occlusion arterial collateral circulat on alter 78-9 gangrene due to 17 masculas reaction to 118 191 1.3 and pallas 17 symptoms 42 traumassc causes 43 chronic progresse 91 embols and thromi ore dureret atson + re toration of our ulatson after B8 surgical pro edure 997 Ocupational disease va a na tre 6% cillogtaplıs 27 Oslonicity 27 O textis deforman 65 teomyel118 45 fropoto > 67 Orygen arteriovenous diference con umprion ng saturation 17 51 upply ani aromotion 12 T'agets disease 65 107 Pan n arterio lerosis 47 n pleural e emert 45 1 otural resor restart to $ asi sen ory tips? 3 11 in a wlar & turt an es 15 Pallor 15 17 C'alpation 17 Pancres 65 anarerine PB l'aritol 95 Veri alır 98 l'entolinsum 81 91 Pertolos trolid nium 89 Terrarter tis 17 13 Petrarhrt 62 63 Perineum 3 Peritoneum I ceral 11 Pern 1 51 Jersbes test 24 Pelechia 17 18 Phaeochromocytona 63 Phenyiharazone 95 Thenylendaned one 97 [ hleb tos, 415 mlra! ry 49 50 55 and senious thrombol *+-15 95 " lefogtaphy 25 Meyers 15 62 Yo ariim infart Myred m 63 la 5 5B 10 Ne - rt al mal 5 hary 111! Inntran 57 on 13 5+ ·152 INDEX l'hlebo clerosis 45 ligmentation 20 51 Pitre sin 61 Mantar i chemia test 20 I latelet achesivenes 26 thrombus 11 I leibysmography 28 30 Pneumonia 43 45 Penumoni 45 Polimyeleti 16 59 Polyarteritis 17 nodosa 51 52 66 Polycythemia sera 53 (5 Position and color channes % 17 ky posen lon due in 8185 in teste for insuff cuency 23 in therapy 95 98 Postphlebitic syndrome 51 I regnancy and anticoagulants 97 rreure during 45 and telangiectasia 56 apul sarico e veine 55 Pres ure arterial 45 teste for 21 and arteriovenous fistula 41 Iloot during sleep 14 high. See flypertension an comotos Te ponses 19 fram cervical rily 41 gradient in capıllary lesopa 19 liydro tatrs 86 Intracarillary 10 venous letermination 25 Pri coline 89 91 I rocaine 88 91 I rotonline 96 I rothromlan te ts 26 Prothrombin time 95 9 Pule 3 Pulle inarteriosclerosis 47 palpation for 1 18 Iurpura l. 18 52 thronbotic thrombocytopeni 41 65 I yemia septic 98 Salkylates 98 Sarcoma 57 58 100 Saunders vasoscillating bed 86 Scalenus antkus syndrome 64 Scarlet fever 43 16 Scleroderma 16 52 53 Sclerosis aortic 50 brachial and radial arteries 50 diffuse 47 media and nodular 46 Sensitiysty 59 65 66 and antihi tamine 102 Ser 914 45 Septicemia 43 Sequs ol 99 Shelter foot 55 Shock 6+ Shoulder hand syndrome 69 63 Shunt 41 138 hemodynamic respon e 51 within muscle 133 Side effects of anticoagulants 95 of vaso Jilator drug 99 Skeleron See Muscle Skin atrophie 16 capillaries 10 color changes 19 in deep venous thrombose 45 le sons 1" 52 macro and micromesh pattern 145 neural met hanı min 13 responses to Gibt on Landes procedure 61 to stimuli 14 to warming 59 6 sympathetie saso kilators in 12 an type of telingt stasia 56 Smallpox 46 Smoking 18 Sodrum 88 99 Spinal cord le jons 58 59 nerses 1011 thoracico lumlar outllos 10 tras ection 14 Spleen 58 Stereoradiography 125 Steroid gonad 63 Sie somietoancriography 115 125 Streptodorna a 107 103 Streptokinas 102 103 Sirokes 58 Sudecks atroly 67 63 Sulfonamide 98 Sympathe tomy 59 6? and arterial resection 85 in rerel ral vascular in case 102 indications for 93 91 preganglionie 93 vasomotor re pon es 59 61 91 Sympathetic nenou s tem 1 13 Syncope 62 Syphilts 49 101 Syringomyelia 59 Radiation therapy 100 Radiography 21 ham communicantes 10 hayngu is di ea 16 59 53 management 91 symmetrical gangrene 6? Regitine 89 Hendu Olers It ea a 100 Rendu ler Welet dhea e 56 Respiration and adrenergic I lorka le agents 92 and cyano 19 17 Retina involvement in arteriosclerosis 18 Rheumatic fever 43 52 Ronjacol 88 Houget cells 5 Rouget lejer cells 6 Rumpel Leede s test 79 Tales for alls 59 Taly arda 11 92 ·INDEX 153 Thrombus furable 98 occlusion due to 8185 platelet 41 surgical treatment for 85 Thyroid gland 63 Tingling 16 Trauma arterial o clusion due to 44 arteriovenous fi tula due to 51 blood flow after 58 66 occupational 62 ulc ration after 17 and yasoconstriction 77 venous thromio due to 98 Treburon 95 Trench foot 46 5S 100 Tromeran 97 Tuberculo 1 101 Tumor 17 56 malignant 5.58 100 metastatic 45 Tunica ad entitia 5 10 11 intima 511 media 5 11 46 pain 20 Telangiectasias 18-19 types 55 56 Tmperature body re ulation 51 urface 18 dru s for effect on 8.97 and vasodilator stimuli 59 6 Yasomotor re ponses to 14 031 Temporal arteritis 49 50 Tetraethylammonium 84 85 89 91 Tets arterial pres ure 21 I lo d coa ulation 26 Bodie Trendelenh re modified 24 calorimetry 27 Capillary 22 Circulation ome 26 claudication t me or di tance 0 cold pres or 31 exercise 0 Gubbor Landı pro edure 31 Hecht Dalldorf's 22 hustamine flare 2 Kisch 90 Lewis triple re ronse 22 oxygen blood content 29 Perthes 24 platelet count 26 plethysmo raphy 28 po tural color changes 20 'I prothrombın 26 radioa tive ub tances for 99 30 reacti e hyperemia 21 red cell frag I ty 26 Pumpel Leede 22 sal ne wheal 23 su face thrmometry 2. 8 tourniquet 24 Vasomotor responses 30 3? Venous hillipo time 2091 in ufficiency 3 24 Theobromin 98 Theophyilın 98 TE omboangitis 45 and e ebral circulation 58 obliterans 4 49 an migrating phlebiti 49 55 Thromboarteritis 17 Thombocytopenia 41 Thromboembolim 95 Thrombophlebitis 41 45 51 m gratino 50 recurr ng 55 sur 6cial 45 of varicose veins 50 99 and venous in uff ency 94 Thrombophi! 65 Thrombs1 intra ascular 51 54 nd polycy themia 65 restitutio ad integrum 98 sclerosing therapy 99 ptic 97 subclaviante el 65 Yennus 54 55 95 causes 98 deep 45 Ulcer and anticoagulants 94 gast is 49 indolent 59 i chemic 17 107 stasis 20 51 vat cose 20 Ul eration 17 in arteriovenous fi tula 51 exercise sulst tute in 86 manacement 103 Urtica 65 purpura 65 Varico e ve ns 20 55 cau es 25 of literat on of 99 Vasa vasorum 5 82 Va cular bed blood flow shifts in 33 network formation 118 1.5 136 nural mechanism 12 13 12somotor responses 11 12 14 33 77 87 Va cular d seas 16 20 amputat on for 107 101 e ebral 58 101 102 and primary new growth 100 symptoms 15 16 and temperature chances 18 thrombotic 41 treatment 101 101 d ugs for 87 92 Va o onstriction of arteriolar mu ulature 12 and catechol amines 63 counteraction ) y Gil bon Lande pro e lure P1 defined 11 tran mi ton of unpul e 10-11 99 and va odilatat on differentiation of d ord is 67 Te ponses to same stimulus 17 la o! pre nr suhstance 61 ·154 INDEY Vasodilatation antidromic impulses 11 and cerebral blood flow 101 10% after chilling 87 defined 11 drugs for 87 92 in febrile state 30 Cilhon Landis procedure 59 62 reflex 86 and va oconstriction 69 77 Va sercitor material 61 Vasomotion actise 12 alteration with cerebral lesion 58 concept 11 control 10 12 13 and emotional factors 102 druk 14 31 39 90 pathways for 63 responses to cord transection 11 to sleep 14 to sympathectomy 59 tests for 30-32 tone 13 81 85 Va o pa m 17 of arterioles 53 blockade for ol ganglia and nerves 93 regional sympathetic 99 I one atrophy due to (2 pulation in 18 Vena cava 11 inferior + 9 superior 3 Venae comite 3 Venography 25 Venule formation 11 microradiographic studie, 136 Veins anastomosis 138 arterial 6 59 116 137 142 avillary 3 basılıc 2 brachial 23 cephalic 2 cubital 2 drainage See Drainage venous engorgement 41 femoral 4 homeostasis of tone and fressure 61 ilar 4 Intramuscular 136 ol Struction 19 occlusion 23 saphenous 4 122 size and structure 45 spasm 19 subclaytan 3 subpapillary plexus 10 19 thoracic 61 thrombosis 45 98 tibial 4 valse formation 11 Vasomotion fet 12 tualization 25 walls 11 congenital weakness 55 damage in 45 Ventricle output 61 Veratrum 90 Vi cus pelvic 3 stimulation of 11 Vitamin 26 97 98 Tola 2 3 Warfarin 97 Warming 14 59 61 Santhine 98

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