Edgar V. Allen

Erythermalgia (erythromelalgia) of the extremities

Abstract A clinical syndrome has been described which was designated “erythromelalgia” by Mitchell and for which we suggest the term “erythermalgia,” thus indicating its three important components, namely, redness, heat, and pain. This syndrome, which may affect one or more extremities, is characterized by discoloration and distress, both of which are dependent entirely upon the temperature of the skin, the increase of which constitutes the third component. The condition may occur as a primary disturbance, or it may be secondary to such conditions as polycythemia vera. The diagnosis depends on the establishment of a close relationship between the occurrence of the distress and the temperature of the skin. When the temperature of the skin increases above a critical point, the distress occurs; when it decreases below the critical point, the distress disappears. The distress itself results from a susceptible state of the skin to increased temperatures, a condition which does not occur in normal persons. The diagnosis is relatively simple; the treatment may be unsatisfactory.

The vascular complications of polycythemia

Abstract Study of ninety-eight cases of polycythemia vera and thirty-five cases of relative polycythemia reveals that erythromelalgia, myocardial infarction, angina pectoris, occlusive disease of the peripheral arteries, cerebral hemorrhage of thrombosis, intraabdominal vascular thrombosis, phlebitis, and vasomotor neurosis occur in about a third of the cases. Recognition of the relationships is mmportant diagnostically and therapeutically.

Dicumarol: Its action, clinical use and effectiveness as an anticoagulant drug

Abstract Dicumarol is a potent and valuable anticoagulant drug. When used properly it appears to prevent intravascular thrombosis in almost all patients. There is considerable and unpredictable variation in sensitivity to dicumarol among different patients. Dosage of dicumarol must be guided by the effect produced in each patient as indicated by the degree and duration of prothrombin deficiency which develops and is indicated by determinations of the concentration of prothrombin in the blood. It is unwise to use dicumarol unless adequate facilities for determining the prothrombin time are available. If the prothrombin is kept between 10 and 30 per cent of normal by administration of dicumarol, thrombosis will almost certainly be prevented and serious bleeding is very unlikely to occur. The action of dicumarol is delayed. When a rapid anticoagulant effect is desired concurrent heparinization is necessary for the first few days. We have found that dicumarol has prevented fatal pulmonary embolism and recurrence or extension of venous thrombosis in patients who have had postoperative nonfatal pulmonary embolism or thrombophlebitis. There is some incomplete evidence to the effect that it will prevent peripheral thrombosis, pulmonary embolism and further coronary thrombosis in patients who have had acute myocardial infarction. Dicumarol with preliminary heparinization is valuable in the treatment of acute arterial occlusion of the extremities. It has also been used safely in patients in whom thrombophlebitis and pulmonary embolism complicated the puerperium and various diseases, in patients with idiopathic recurrent thrombophlebitis and in those with chronic occlusive arterial disease. While statistical confirmation is lacking, it is our impression that in many of these patients thrombosis and embolism have been prevented by administration of dicumarol.

The physiological effects of extensive sympathectomy for essential hypertension

T HIS study of physiological changes resulting from extensive sympathectomy is based on forty-five patients who were operated on for essential hypertension from February, 193.3 to .January, 19.37. Studies of patients operated on since .Jannar-, 1937 are not included in this report. The technique used, which has bee11 described in detail elsewhere,l~ 3 consists of bila,teral subdiaphragmwtic, ext,raperitoneal resection of the splanchnic nerves, celiac ganglions, ant1 the upper two lumbar sympathetic ganglions. The second operation is performrtl about ten days after that on the opposite side. In twenty-five instances partial suprarenalectomy was performetl ; one-third to two-fifths of each gland was removed to see if this woultl acc~rntuate the effects on blood pressure of extensive sympathectomv. Surgical treatment of hypertension has been attempted beeausr it is apparent that there is no means of controlling hypertension adequately. hinonsurgical management, in many instances ; the high mortality from hypertension is adequate testimony for this observation.ls 2 It is known that elevation of blood pressure in essential hypertension is due to a generalized increase in resistance to the flow of blood t.hrough the periphery of the arterial system. The fault, which seems to be that of the arterioles chiefly, appears to be abnormal vaso(aonstriction or increased arteriolar tonus, at least in early stages of hypertension. Later in the disease organic> changes affecting small arteries and a,rterioles may contribute to incarrased resistance f o tilt> flow of blood through them. There is evidence that. at. least in early hypertension, the abnormal state of the arterioles is an expression of abnormal vasomotor stimuli arising ill the vasomotor (*enter> lvliic*h are transmitted to arterioles by way of’ sympat~llrtic* llervcs. 01’ that the arterioles respond with an abnormal state of vasc~~onstrictic)ll OL tonus to normal stimuli transmitted by way of the sympathetic: nervous system. In advanced hypertension the arterioles may assume all independent function of increased resistantde to the flop of 1~10011 through them either by virtue of structural changes or by virtue of an inherently increased tonus independent. of stimnli transmitted OWI. the sympathetic nervous system from the vasomotor center. Goldblatt’s experimental work’ has shown that diminution of blood suppI>, to the kidneys produces hypertension (alosely simulating essential ]I>--

Surgical treatment of acquired arteriovenous fistulas

F OR many years quadrupIe ligation and excision has been the method of surgical treatment of acquired arteriovenous corn munication. Recent investigations,9 particularly in centers caring for war casualties, suggest a reduced incidence of arteria1 insuffrciency when arterial continuity is re-established by end-to-end anastomosis, homoIogous artery graft or autogenous vein graft. Figure I illustrates a situation found frequently in our series. Stimulated by these recent innovations in vascuIar surgery, we have undertaken a study of thirty-two patients afFEcted with traumatic arteriovenous IistuIa of a limb; the treatment in each had consisted of interruption of the arterial and venous circuIation in the limb by means of Iigation and excision of the involved vesseIs. SurgicaI specimens were submitted to gross and microscopic examination; questionnaires sent to patients afforded the foIIow-up evaluation of each limb treated by Iigation and excision. Particular emphasis was pIaced on adequacy of the interrupted arteria1 and venous circuIation. Although much has been written from earIy times about the arteriovenous fistula, it remained for WiIIiam Hunter in 1739 to distinguish it from a simpIe aneurysm; he was the First to give a detailed description of the signs, symptoms and physica findings of the affliction. The major cIinica1 manifestations are a harsh thrill and a bruit in the involved area; these are continuous throughout the cardiac cycie with systolic accentuation. The rapid passage of arteria1 bIood into the venous circulation may resuh in marked elevation of the venous pressure and thence in chronic venous insuffrciency with varices, edema and stasis pigmentation; aIso, one sees ulceration of the limb. Figure 2 shows the increased venous pattern and generalized enIargement of the limb with a Iong-standing fistuIa.‘*Another frequent Iinding is cardiac enlargement. One may make a diagnosis of acquired arteriovenous fistula when a thril1 and a bruit are observed in the region of a penetrating wound: the presence of chronic venous insuffrciency and increased warmth in such a limb in the region of the fistuIa is further evidence of an arteriovenous shunt. In our experience arteriography was not necessary to enable one to estabIish the diagnosis.

The Use of Sulphur for the Production of Fever in Peripheral Vascular Diseases

Excerpt The artificial induction of fever as a therapeutic measure in peripheral vascular disease has been well demonstrated. Its value rests on an increase in the circulation through the extremiti...