Peripheral vascular obstruction in rheumatoid arthritis and its relationship to other vascular lesions.

Gangrene of the terminal portions of the limbs may be due to obstruction in the peripheral vessels, large or small, or it may be associated with cardiac failure as in rheumatic or ischaemic heart disease (Swan and Henderson, 1951), with ball valve thrombi, or with pulmonary disease (Boulet, Serre, Vedel, Vallat, and Mirouze, 1949; Hejtmancik and Bruce, 1953). In a case of mitral stenosis and gangrene of the limbs and nose, in which I dissected the finger vessels and studied them in detail, no pathological changes were seen: the process had been thought to be one of low output and vasospasm. Obstruction peripherally may be due to primary changes in the blood, as in cryoglobulinaemia (Myerson and Stout, 1955), or to cold agglutination (Stats and Bullowa, 1943), but is more usually due to primary vessel disease, as in polyarteritis nodosa (Taylor and Jacoby, 1949), Buerger's disease, giant cell, or temporal arteritis (Chasnoff and Vorzimer, 1944), to multiple embolization, or to vasospasm, as in Raynaud's disease or crutch arteritis (Stammers, 1954). In scleroderma it seems possible that vessel changes precede the skin sclerosis. Occasionally, however, an unusual type of peripheral arterial obstruction has been found which does not fit easily into any of the above categories (Whiteley and Wilson, 1952). It is the object of this study to describe such clinical and pathological changes occurring in the course of rheumatoid arthritis, and to discuss the relationship of these changes to those found in generalized lupus erythematosus, to the better-defined entities listed briefly above, and to the rarer ill-defined group of published cases not easily accommodated within these diagnostic pigeonholes. Some years ago an account was published of six patients whose early clinical course resembled palindromic rheumatism, but who later showed clinical and radiological signs of rheumatoid arthritis and, in addition, some other curious features, notably cutaneous nodules (Bywaters, 1949). One of these patients (Case 2) later died with gangrene of all four limbs. The present study describes the progress and terminal stages of this case, together with nine other examples of peripheral vascular obstruction (Table, opposite).