A CASE OF THROMBOANGIITIS OBLITERANS.

By M. N. PAI,

CAPTAIN, I.M.S. (T.C.), Indian Military Hospital, Poona.

,,HnHEKto as far as I am ??aL??in Wk

^hrombo-angiitis has been 1 P facts about

A brief resume of some of the kn ieref0re, be

this rather obscure disease may >

of interest. niossified as organic diseases of arteries are

clas , thrombo- *nd functional. The former

mclua ftud?s

angiitis and arteriosclerosis, w 1 iianrres?and

disease?due to vasospastic phenomena ?erythromelalgia?due to vasodilator

1

?form the functional group. inflam- This disease has been definec

<

^ unknown matorv disease of the blood

vess -

disease

origin (Buerger). The exact cause

is unknown though several predisposing iaciors undoubtedly play an important part in its causation. Silbert (1927) attributed it to

smoking, but several cases have occurred among non-smokers. The earliest cases on record occurred chiefly among Russian and Polish Jews, but recently cases have occurred in London, America and .even China. No age is exempt though among the Russian Jews in London cases occurred among persons between 10 to 60 years. Bowers has recorded cases of

gangrene of the nose in children under 10 years. At first these latter cases were thought to be due to diabetes, but the balance of opinion was in favour of gangrene due to Buerger's disease. There are three well-known types of the

disease.

(1) Early type, limited to the lower extre- mities without gangrene.

(2) Chronic type, with gangrene of one or

both lower extremities.

(3) Chronic type, with involvement of upper and lower extremities.

The onset begins with numbness and pain in the legs followed by gradual and progressive absence of pulsation, first in the smaller arteries like the dorsalis pedis, then in the larger arteries like the posterior tibial and popliteal. In the later stages oedema occurs with certain trophic lesions accompanied by excruciating shooting pain which ceases with the commencement of

gangrene. Absence of pulsation in the arteries is noted long before gangrene commences. Where gangrene sets in early the prognosis is bad, otherwise there are long periods of remission and the course sometimes extends to as many as

twenty years. In one type of this disease there is sudden

onset of spontaneous pain, pallor and later

cyanosis of one or more toes which rapidly ulcerate. The extreme pain is said to be due to the fact that the nutrient arteries of the nerves are frequently the site of this process, while Silbert believes that the pain arises from the fact that the nerves undergo complete dege- neration as a result of being gripped in the fibrous tissue which surrounds the blood vessels.

Pathology.?It is not proposed'to go into this in detail, suffice it to say that in one case Gird- wood found that the arteries, vena} comites and nerves were all matted to each other and to

the surrounding tissue by dense fibrosis. Histo-

logically the lumina of the arteries was occluded by a thrombus which had become re-canalized. The internal elastic layer was thrown into folds by contraction and dense cellular infiltration was seen in the media around the vasa vaso- rum. The muscular coat, the adventitia and the surrounding tissue had undergone fibrosis.

Diagnosis.?Robert N. Grier remarks that more than 80 per cent, of cases of thrombo- angiitis obliterans seen at the Mayo clinic were previously diagnosed incorrectly. Though in

432 THE INDIAN MEDICAL GAZETTE. [Aug., 193L

about 30 per cent of cases of thrombo-angiitis Raynaud-like phenomena are present yet evi- dence of obstructive arterial disease will always be found on careful examination. In the case of the upper extremities, intermittent pallor and

cyanosis, the early symptoms of thrombo-

angiitis, may be mistaken for Raynaud's disease. Treatment.?" The pain which is the chief

symptom makes life unbearable. Many treat- ments, most of them unsuccessful, have been tried in order to give relief. Counter-irritation and passive hyperemia are useless. Morphia and its derivatives are dangerous, because the injections have to be repeated and in the end become ineffective. Surgical methods are decep- tive. Arterio-venous anastomosis is illogical, for both vein and artery are thrombosed.

Tvine: the femoral vein has not been success-

ful." Therefore treatment to be effective should

aim at:?

(1) Complete relief of pain. (2) Permanent healing of trophic ulcers. (3) Checking of gangrene. In the past when once the disease was defi-

nitely diagnosed as such, amputation was the only treatment adopted irrespective of the

stage of the disease, but the modern tendency is to reserve this measure of treatment only for those cases where actual gangrene has set in or where other remedies have failed.

Recently, Rontgen-ray therapy has been tried with various degrees of success. Buerger sug- gested arterio-venous anastomosis. Among drugs sodium citrate has been given by the mouth and intravenously. Ten grammes of the salt per day divided into five doses have been recommended for a fortnight and the dose sraduallv reduced thereafter (Lian and Barrier, 1923).

Steel employs a solution of 2 per cent, sodium citrate intravenously, 250 c.c. of this are given every second day and the legs are placed under a hot air electric bath at 110?. Daily leg mas- sage is given and the patient put in a wheel- chair with feet hanging down a short time each day. Increased walking is permitted as evi- dence of a functional collateral circulation

appears.

Potassium iodide is given during the whole course of treatment and is well borne. As a

result of this treatment collateral circulation is

established; ulcers heal and gangrene is pre- vented. Steel claims to have treated six cases, out of whom five were completely cured and the sixth was relieved to a considerable extent.

In 1915 Mayesima showed that there is in- creased viscosity of the blood in these cases and Ringer's solution hypodermically over long periods is therefore advocated (Koga).

Silbert (1927) uses a 5 per cent, solution of sodium chloride, 150 to 300 c.c. of which are

given intravenously twice or thrice weekly.

The writer's case.

Sepoy Balu Rama, a non-smoker, aged 30 years, complained of two small ulcers on his right foot. Previous history.?No previous history of syphilis,

diabetes, etc. On 7th March, 1930, the patient felt

slight pain in the toes of his right foot and observed the next day that two small blister-like swellings had appeared one on the great toe and the other on the

little toe. These subsequently became purulent and a few days later the nails of the great and the little toes fell off. Since then the ulcers have not healed and the patient feels acute gripping pain shooting up the

right leg. The question of amputation having been

considered he was transferred to this hospital on 23rd

April, 1930. Local condition on admission.?The whole of the

right leg is colder than the left and pulsation of the

popliteal, posterior tibial, and dorsalis pedis arteries cannot be felt. There is a clean anamiic-looking ulcer, ot

the size of a rupee, on the great toe in the region of the nail. The edges of the ulcer are clean, sloping inwards and extremely painful to cutaneous stimuli. There is

complete absence of surrounding inflammation. A similar but smaller, ulcer is present on the little toe. The

surrounding skin and subcutaneous tissue are cold to

the touch, but sensation is not impaired. The femoral glands of the right side are not enlarged. There is

area of anaesthesia. Pain is relieved by walking and

the patient feels better while hanging his legs doWB-

His right radial pulse is thinner in volume than the

left. All other systems and organs normal. Wassermann reaction negative.

Differential diagnosis. 1. Raynaud's disease.?This is rare in 3

tropical country, and occurs usually between the

ages of 15-20 years, among delicate, antemic, hysterical or emotional and easily excitable persons, chiefly women; it is symmetrical and the parts affected are cold and completely anaesthetic. All the toes or all the fingers are

affected at the same time and the pulse though thin is always perceptible.

2. Syphilitic endarteritis.?Absence of history and enlarged glands and negative Wassermann exclude this disease.

3. Erythromelalgia.?In this disease the

veins are enlarged, the arteries throb visibly? walking or hanging the legs down makes the

patient worse. 4. Leprosy, diabetes, gangrene due to drugs?

and syringomyelia are easily excluded. 5. Intermittent claudication?arteriosclerosis

is generally present and walking makes tne

patient worse. 6. Spontaneous gangrene.?Occurs in persons

with arteriosclerosis, usually in women during tn

puerperium. The gangrene is usually dry an a distinct line of demarcation forms and there is complete loss of sensibility in the part. ,

Diagnosis.?The coldness of the limb shooting pains in the leg, loss of pulsation the arteries and absence of the cardinal signs

?

gangrene are in favour of thrombo-angin1 :

The fact that only one limb has been affected an^ that during these several months the disease

na

remained stationary suggests the comraenceine of a collateral anastomosis. The fact that tn^ patient feels better after walking is also in con

formity with the above diagnosis.

Aug., 1931.1 NOTE ON URINARY NITROGEN: HUGHES, MALIK & SAHAI. 433

Treatment.?During his stay in

was given syrupus ferri iodidi and co

- '

Locally, the limb was wrapped in cotton-^001

and radiant heat was given thrice w ?

Ten grammes of sodium citrate a ay,>

into five doses, were given for a iortnit,

?

He showed considerable improveme his stay in hospital; the ulcers

bega , ^ and on 4th August, 1930, he wa? .

'

^ 0f with a recommendation for invalidi g

the service. His subsequent history is

as follows.---^ % the end of September 1930 1j^ormeared

completely healed, his pain entirely dis< pr

and he is now moving about like a noin.V , \ v

This case is similar to those describec y

eber, Rast and Lutterotti (1930) "fti 1

important difference, Balu Rama is a

smoker and the cure is mainly attributabl

diathermv * lermy.

Shettle Referring to this case Lieut.-Colonel F.

B.

o.b.e., i.m.s., says: , ,,,rombo- " This case was undoubtedly on ^ such

angiitis obliterans. I have seen. There is cases previously during s"'^nme 0f those food for thought as to whetlie

-

^on-inflam- Pale, pasty, anaemic, indolent, pit

>

or feet, matorv, recurring ulcers of the

healing which are sometimes never-healing me jn with the greatest difficulty, may

n

tWfTheses are familiar to *

out-patient departments of civi? soidiers." are hardly ever seen amongst se

b ^ ^

Shettle1'1?1'5 are dUC ^Officer "

Commanding, tl rV

0 B E-' 1'M ?V !?r Poona, not only the Indian Military Hospital, ublish these for his advice and permission P , use 0f

notes, but also for allowing me to ma

his library.

Li? n References^ mdicaX Annual, Lian, C., and Barrier, It- (^2 ''

P- o3. . 489- Silbert, S. (1927). Medical Annua , V^ Q- (193o). Weber, F. P., Rast, H., ?nd ̂ ut

Brit. Med. Journ., Vol. II, P- 279.

(The author's meaning is noi

ention diathermy as having been n ̂

"eatment in this case.?Editor, L M.

. he does not

not clear > d in the