An exercise test in intermittent claudication.

In most cases of intermittent claudication the diagnosis is apparent after the history and clinical examination have been completed. Although the history itself may be misleading, clinical examination is usually fruitful; the signs of obliterative arterial disease are present in most, and cases of anrmia and coarctation of the aorta that present with intermittent claudication should be easily diagnosed. However, in a number of cases the diagnosis remains doubtful. Andre-Thomas and Levy-Valensi (1918), and Andre-Thomas (1922) found in patients with intermittent claudication a diminution in oscillometric pulsations after exercise. Comroe (1923) finding a diminution in the peripheral pulses of intermittent claudication patients after exercise, believed that arterial spasm might be responsible even in the absence of obliterative arterial disease. Pearl (1937) reported six cases showing a similar phenomenon. Similar cases have been reported by Leary and Allen (1941) and by Lindqvist (1945a, 1945b). The latter stressed the value of oscillometry after exercise in diagnosis; he believed that the diminution in pulsations which he found was evidence of vascular spasm, rather than a sequel of obliterative arterial disease, implying a functional rather than an organic lesion. Arterial spasm itself as a source of pain in intermittent claudication was denied by Lewis et al. (1931); Leriche (1937) and Ejrup (1948) further supported Lewis's view, as do our findings. In 1944 Ejrup published an account of an instrument which after modification he considered would act as a tonoscillograph; he defined this as an instrument for measuring and recording variations in the pulsations and pressure in a vessel (Ejrup, 1948). His apparatus has the advantage of enabling continuous recordings to be made both before and after exercise. He studied the appearances of tonoscillographic tracings obtained before and after exercise in normal subjects and in those with intermittent claudication. Normal subjects showed an increase in the magnitude of pulsations and an apparent increase in blood pressure after exercise. Cases of intermittent claudication showed a decrease in the magnitude of pulsations after exercise, and an apparent fall in blood pressure distal to the site of arterial obstruction in the affected limbs. This phenomenon Ejrup termed the " inverse reaction." He also found the inverse reaction in some cases of anemia (Ejrup, 1949), and of coarctation of the aorta; the inverse reaction was not found in cases of Raynaud's syndrome. The following is an account of normal persons, patients with intermittent claudication, and those with pain in the leg due to other causes than obliterative arterial disease, studied with Ejrup's tonoscillograph before and after exercise. This investigation was made to evaluate tonoscillography after exercise in the diagnosis of intermittent claudication due to obliterative arterial disease, to correlate tonoscillographic and arteriographic findings, and to determine whether tonoscillography after exercise could be used in place of arteriography in the location of arterial obstruction. We further wished to discover whether the inverse reaction could be recognized clinically.'