The Early Diagnosis of Thrombo-angiitis Obliterans: A New Diagnostic Sign

The differentiation of thromboangiitis obliterans, arteriosclerosis obliterans, and embolic disease has long been fraught with confusion. In 1908, Buerger[1] described a specific nonatheromatous lesion involving arteries, veins, and nerves that frequently led to the development of gangrene in individuals who were significantly younger than those presenting with gangrene caused by arteriosclerosis obliterans. As recently as 1960, Wessler et al[2] questioned the existence of thromboangiitis obliterans. Present thought is that the more thorough the diagnostic techniques are, the rarer thromboangiitis obliterans becomes.

This confusion is evident in the article reprinted here. Saul Samuels describes excellent clinical tests, still relevant today, that can be used to diagnose poor arterial flow in the skin of the feet. However, his tests are not specific for the diagnosis of thromboangiitis obliterans. If Samuels had titled his article “Simple Office Diagnostic Tests to Determine Decreased Arterial Flow into the Feet,” it would still be relevant today and worthy of publication in current journals.

While reading this article, I was surprised by the many subtle and valid diagnostic points made by Samuels that are not always recognized by today’s physicians using more sophisticated diagnostic technologies. Following are several examples of his acumen. Samuels writes that if a pulse is felt in the posterior tibial artery, it should not be assumed that there is adequate flow in the plantar arteries. I wonder how many physicians today do not recognize that there can be diminished pedal arterial flow even if pulses are palpated. The test that Samuels describes can easily unmask this type of distal ischemia.

Samuels’ observation about congenital absence of the dorsalis pedis artery and resultant increased flow in the peroneal artery is also not as consistently recognized today as one would hope. However, I would have liked Samuels to indicate that he understood the extensive interconnection between the dorsal and plantar arterial vessels. That way, dorsal and plantar arterial flow would not have seemed so distinct and separate from each other in his description.

Samuels’ description of his test in which the subject, while reclining, elevates both legs and dorsiflexes and plantarflexes the feet is an early precursor to several stress tests that are used today to determine arterial adequacy. His description of the pallor that ensues in arterial disease is still valid today. Samuels’ test is an early version of the postocclusive 5-min reactive hyperemia test described in podiatric textbooks.[3] This test accurately identifies subtle arterial inflow problems secondary to atherosclerotic or embolic sequelae, without necessarily requiring any instrumentation.

Despite the article’s title, Samuels’ comments are applicable to evaluation of arterial insufficiency in the feet secondary to any arterial occlusive or embolic phenomena. These descriptions are as relevant today as they were in 1930.