422 S.A. MEDICAL JOURNAL
CLINICAL PLETHYSMOGRAPHY*
ROBERT H. GOETZ, M.D.
Department of Peripheral Vascular Disease, Groote Schuur Hospital, and the Surgical Research Department, University of Cape Town
(Conrinued from page 401)
10
July
1948In addition to information furnished by the pulse yolume and digital volume, the plethysmogram pennits measurement of the actual rate of blood flow through the digits, by means of the so-called venous congestion test (Goetz, 1943; 1946). In brief, the test con ists in arresting the yenous return from the digits by mean of a blood pressure cuff fixed at the ankle. the wrist or on 'rue' digit 'itself,
\\'ithout impeding the arterial inflow (Figs. 2 and 16).
In order to obtain comparable and reliable results, yenous congestion should be applied quickly, if possible from one heart-beat to the next. We there- fore first pump up a reservoir (Fig. 16) from which, by turning a tap, the cuff can be filled instantaneously. Two manometers are connected, one (lVh) for reading the pressure in the reservoir, the other (M2 ) for reading the pressure in the cuffs.
.-\ glass plate manometer (M3) simultaneously records the cuff-pressure on the film as it is applied.
* Read in part before the South African Medical Congress, East London, October, 1947.
On applying the pres me, the digital volume at first increa e with each heart beat along a straight
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C):r.
Fig. 16. Arrangement used for sudden inflation of cuff during venous congestion test as builtinour portable plethysmograph.
The pressureinthe cuff is simultaneously read (M2) and recorded
!M3). R ~ reservoir and manometer (MI)to indicate pressure
i l lreservOir. For explanation see text.
Fig. 17. Typical tracing of venous congestion test. P =record of pressure in cuff. For explanation see text.
10Ju/ie1948 S.A. TYDSKRIF VIR GENEESKUNDE
·~q:r:r·n·
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- - - -
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Fig. 18. Venous congestion test during various states of vasomotor tone in a normal individual.
A. Constricted. B. During dilatation. C. Fully dilated.
P. = Record of pressure in cuff. SK.T. = Skin temperature.
423
424 S.A. MEDICAL JOURNAL 10
July
1948line (Fig. 17). If the venous congestion is left on long enough, the vascular bed of the digit fills and the tracing slopes gTadually towards the horizontal and eventually runs parallel to the base-line (Fig.
17). When the pressure is released the tracing returns, as a rule, to the original level. During the first part of the tracing the rise in digital volume i3 proportional to the arterial inflow. Consequently, the rate of blood flow (per minute for 100 C.C. tissue enclosed) can be mea ured by a simple formula (Goetz, 1943: 1946). The results obtained with this method arc n:rv consistent and enable evaluation with great accu~acy as long as the pressure of the cuff is \yell below diastolic pressure and above 30 mm. Hg.
The rate of arterial inflow natural~y will depend upon the height of the pulse volume, i.e., upon the vasomotor tone in the normal subject. The higher the pulse volume, the greater the arterial inflow. A typical example of the venous congestion test in a normal indi\'idual under \'arying states of vasomotor tone is gin:n in Fig. 18. In Fig. ISA the vessels are constricted and the pulse volume hardly registrable. The arterial inflow is consequently minimal and in 2 seconds rises only about 1/6 of a division. As the vessels relax and the pulse volume increase (Fig. ISB). the arterial inflow for two seconds i about two divisions. When fully dilated (Fig. ISC) the arterial inflow per two seconds easily reaches 5.5 diyisions. The rate of blood flow there- fore increased 33 times from Fig. ISA to lSC. The rate of blood flow in normal subjects thus calculated -yaried between I C.C. during full constriction and 90 c.c. per minute for 100 C.C. tissue when fullv
dilated (Goetz, 1943: 1946). .
In general, there is a direct relation between the height of the pulse volume and the gradient of the arterial inflo\\' on venous congestion, but careful scrutiny of a large number of tracings demonstrates that this is not always the case. This is well illustrated in Fig. 19, obtained in a normal individual during body heating. Between Fig. I9A and 19B, 20 minutes' body heating took place. On comparing the two, a marked increase both in pulse volume and the rate of blood flow is recorded. There is release of vaso- constrictor tone. Fig. 19c was obtained ten minutes' later. Although no further increase in digital volume has been registered, a marked additional increase in the rate of blood. flow is recorded. This further increase is due to the opening of small collateral vessels in \yhich the blood is flowing con- tinuously rather than pulsating, as in the larger yessels.
Body heating may, on rare occasions, not be an adequate procedure
JO
dilate the vessels in the lower extremities of some 110rmal subjects. However, it i;; more often observed in cases of spastic vascular disease such as Raynaud's phenomenon or acro- cyanosis. In such cases prompt relaxation of the yessels is only obtained by immersing the limb itself in water of 40° C. It can thus easily be demon-strated that we are not dealing with an organic occlusion but merely an abnormal (local ?) vaso- motor spasm. This finding may be of considerable
Fig. 19. Venous congestion test during various states of ,asomotor tone in a normal subject.
A. During rest. . .B. During dilatation.
C. Fully dilated.
Note opening of collaterals between B and C. For explanation see text.
10
JuIie 1948
S.A. TYDSKRIF VIR GENEESKUNDEFig. 20. Plethysmogram of right and left first toes in a case with trench foot affecting the left foot only.
A and B. During rest.
C and D. After 30 minutes' body heating.
E. After the additional local application of heat to the left foot.
Note diminished blood flow in both feet during rest and failure of left foot to dilate on body heating.
425
426 S.A. MEDICAL JOURNAL 10
July
1948importance in explaining the pathogenesis of Raynaud's phenomenon and allied conditions.
Similar findings are common in cases suffering from trench foot. One such case (which is also representative of what has been said above about Raynaud's phenomenon) is referred to in Fig. 20.
All the pulses were felt in both feet and the patient suffered in the left foot from the typical vasomotor neurosis seen in late cases of trench foot. During rest the peripheral circulation of both feet was markedly diminished (Figs. 20A and B), the pulse yolume hardly being registrable. After 30 minutes' body heating the unaffected right leg dilated in the normal manner, the pulse volume increasing to the FlOrmal vasodilatation level (Fig. 20C). The other leg, however, which had been severely affected by frostbite, did not show any relaxation of vasomotor tone (Fig. 20D). It is well known that frostbitten limbs may develop organic vascular disease, and this question therefore arose. The left foot was immersed in hot water for ten minutes and the plethysmogram recorded thereafter (Fig. 20E)
showed a normal pulse volume.
Whenever a patient with symptoms referable to the peripheral circulatory system is seen, three questions arise:-
I. Is the interference with the blood flow organic or functional (spastic) in nature?
2. If organic, how advanced is the occlusion and to what extent are the vessels still capable of dilatation?
3. To what degree has the collateral circulation been developed?
It is true that skin temperature measurements will furnish some information, but it is the knowledge of the exact amount of blood flowing through the part which is so particularly helpful in assessing the degree of 'an organic occlusion, especially when it comes to the determination of the collateral circulation.
In the following, reference will be made to the plethysmographic findings in a number of typical cases of peripheral vascular disease.
Fig. 21 was obtained in a man suffering from typical attacks of Raynaud's phenomenon. Fig.
21.-\ was recorded when he arrived at the laboratory.
:\!' 0 signs of any vascular disturbance were detected at the time, both limbs were pink in colour and not cold to the touch. Both the record of the radial artery and the plethysmogram gave normal values.
Al1 attack was then induced by immersing the hands for IS minutes in water of 12° C. The plethysmo- gram taken at that time (Fig. 2IB) demonstrates complete arrest of the blood flow thro~tgh the digits while the pulsations of the radial artery were 1Inaffected. When the hands were immersed in water of 40° C. for ten minutes the attack promptly subsided and the digi~al volume registered 0.012 C.C.
(Fig. 21C). Incidentally, there was also relaxation of the radial artery, as indicated in the sphygmo- gram.
The plethysmogram of another case of .Raynaud:S phenomenon is illustrated in Fig. 22. ThIS figure IS of particular intere t since it demonstrates the
Fig. 21. Plethysmogram of second left finger and sphygmogram of left radial artery simultaneously recorded in a case of Raynaud's phenomenon.
A. During rest-no attack.
B. During an attack. . ' .
C. Mter relief of attack by ImmeI"l"lflg hands lfl warm water.
Note complete arrest of ultimate circulation in B but undiminished excursions of the radial artery.
marked contrast that exists between the pen- ultimate circulation as judged by the excursions of the radial artery and the ultimate peripheral blood flow, as indicated by the plethysmogram. Oscillo- metry obviously cannot give us any information as to the peripheral circulation in the strict sense.
Fig. 23 illustrates a typical venous congestion test obtained during syncope in a case of Raynaud's phenomenon. The blood flow is completely arrested.
Fig. 24 was obtained in one of our cases of acro- cyanosis. The patient suffered from marked cyanosis of both hands and feet extending to well
10 Julie 1948 S.A. TYDSKRIF VIR GENEESKUNDE 427
Fig. 22. Plet.hysmogram of the fourth right finger and sphygmogram of radial artery simutaneously recorded between attacks in a case of Raynalld's phenomenon. Note extreme contrast between penultimate (sphygmogram) and ultimate (plethysmogram) circulation.
Fi~. 23. Venous congestion test i~ a cas£' of Raynaud's phenomenon dnr~g an attack. Plethysmogram (third right finger), skill temperature and respiratIOn sunultaneously recorded. P. = pressure In cuff. Note complete arrest of circulation.
-128 S.A. MEDICAL JOURNAL 10 JUly 1948
above the wrists and ankles. Plethysmographic tracings taken during rj!st (Fig. 24A) on arrival of the patient at the laboratory showed complete absence of any pulse yolume. The hands were cyanosed. cold and clammy. The venous congestion
[t;!S[ (Fig. 25B), howeyer, showed that, although
FIg. 24. Plethyamogram of a case of acrocyanosis at rest (A), during body heating (B) and after 20 minutes' body heating (C). .Note ext:emes. between blood flow during rest and durmg full dilatatIOn.
extremely diminished, the blood flo\" was not com- pletely arrested. On body heating all vasomotor tone wa rapidly released within 20 minutes and when fully dilated the pulse yolume was excep·
tionally large (Fig. 24C), indicating the true vaso- motor neurosis of this condition. The extreme difference between the artt'rial ·inflow recorded during rest and during full dilatation in the same case is well illustrated in Fig. 25,
F' 'r Venous congestion test of same case as Fig. 24.
A~gF~Y dilated. B. During rest.
Fio' 26 was obtained i~ a patient who presented with "" ~ sudden onset of numbness an? coldness of his le.ft leg. On examination the penpheral pulses of the right leg only could b~ felt. Th.ere w~s no r('ason for an embolus. no hIstory of mtermlttent
10 Julie 1948 S.A. TYDSKRIF VIR GENEESKUNDE 429
claudication or previous spastic vascular disorder.
The c ntral nervous ystem was normal. The plethysmogram of the left leg during rest showed a definite diminution in blood flow, particularly when compared ,,·tih the right one, which was simul- taneously recorded. With body heating (Fig. 26B), however, the pulse volume in the left leg easily increased to the normal vasodilatation level and was
111 no wa\· -maller than the normal unaffected leg.
Fig. 26. Plethysmogram of left and right first toes simultaneously recorded in a case with unilateral arterial spasm.
A. During rest. B. Fully dilated.
'Ye were, therefore, dealing with a unilateral arterial spasm. The cause remained unknown and on sympathectomy there was a dramatic disappear- ance of the symyptoms.
Fig. 27 is characteristic of a case with typical symptoms of intermittent claudication in the right leg only. On clinical examination the pulses were not palpable in the affected limb but were present
In the unaffected one. Plethysmographic tracing~
taken during rest (Fig. 27A) demonstrate almost
Fig. 27. Plethysmogram of left and right first toes simultaneously recorded ip a case with markedly diminished blood flow in bo~h legs d';ll'ing rest (Al. After body heating (Bl blood flow III left 11mb normal but markedly inter- fered with in the right one. There was marked spasm in the left and moderate superadded spasm in the right.
430 S.A. MEDICAL JOURNAL 10 July 1948
complete absence of any pulse volume in the affected leg. The plethysmogram of the left leg, simul- taneously recorded, shows only an irregular tremor which doe not permit any accurate measurement of the pulse volume in that limb. When fully dilated (Fig. 27Jl), the pulse volume in the unaffected limb increases almost to the normal vasodilatation level. In the affected limb there is an increase in pulse volume too, but it stops at 0.005 c.c. The vascular interference in the right leg is, therefore, for the greater part organic in nature and only a smaller degree is due to superadded spasm.
The yenous congestion tef.t of both legs, simul- taneou Iy recorded, during full dilatation (Fig. 28)
failed to reach the normal vasodilatation level (Fig.
29B), although it is slightly higher ·in the left (unaffected) limb. There was, therefore, a marked degree of superadded arterial spasm,· the organic interference being responsible for the lesser part of the diminution only, as indicated by the difference between the height of the pulse volume during re t
and during full dilatation. Although the patient complained of symptoms in the right leg only, it i:- obvious that the circulation of both legs is affected.
l>einrr only slightly more advanced in the right leg.
The two following figures are reproduced to demonstrate the value of the method in indicating the degree of collateral circt41atioll. Fig. 30 wa
Fig. :2 . Yenous congestion test in both legs simultaneously recorded in same~case as Fig. :2i. For explanation see text.
reveals that the rate of blooa flow in Lhe affected limb is about one-third of that of the unaffected one.
The diminution in the arterial inflow in the affected limb is 110t as advanced as one would have expected from the diminution in pulse volume, indicating that we are dealing with a good collateral circulation.
Firr. 29 is an example of another case suffering from intermittent claudication in the right calf only but with coldness of both feet and cramps at night.
During rest hardly any pulse could be recorded in either leg (Fig. 29A). On body heating the pulse volume of both feet increased markedly, but in both
obtained in a case in whom there was complete organic occlusion. The pulse volume, both during;
rest (Fig. 30A) and during full dilatation (30B),
i 's
not registrable. Venous congestion before and after body heating gives identical (markedh·
diminished) values, but indicates that, despite the complete occlusion of the main vessels, the col- lateral circulation. although poor, is sufficient for the nutrition of the tissues.
Compare Fig. 30 with Fig. 31. also obtained in a case of complete organic occlusion. Although there is almost no increase in pulse volume from Fig.
ID Julie 1948 S.A. T YDSKRIF VIR G ENEESKUNDE 431 31 A to 31 H 011 body heating, the arterial inflow is
markedly increa ed. The increase is due to the op ning of a good collateral circulation. By means of our plethysmographic method we are able to measure exactly the deoTce of the collateral circula- tion. The implications of uch information are olwiou , not only in asses ing the prognosis but in determining the programme and the results of therapy in ,t.;·eneral and of sympathectomy III
particular.
Fig. 29. Plethysmogram of left and right first toes in a patient with markedly diminished blood flow in both limbs during rest and typical intermittent claudication in right one.
A. During rest. B. Fully dilated.
This point is particularly well illustrated by Fig.
32. Although in the one case (32A) the pulse volume is hardly registrable and in the other (32B) it is normal, venous congestion produces practically the same rise in digital volume and the rate of blood
flow per c.c. of tissue was therefore practically the same! In the one limb the blood circulates through numerous small collaterals, and in the other through the normal channels. Such differences in the collateral circulation are responsible for the apparently conflicting re ults obtained from ympathectomy in case of organic arterial disease.
Plethysmographic investigations assist us in sorting out the cases suitable for sympathectomy and prevent u from carrying out the procedure in cases which are certain to fail to benefit by it, thus bringing the operation into disrepute.
Plethysmography lends itself very well to recording the effect of drugs on the peripheral blood flow, both in health and disease (Goetz, 1942; 1948; Bluntschli and Goetz, 1948). The effect upon the blood flow of various types of treatment or the appraisal of the progress made by the patient while under a given treatment can be assessed objectively. Fig. 33 was obtained from a patient who suffered from auricular fibrillation and in whom an embolus had become lodged at the bifurcation of the popliteal artery, completely occluding the main arteries in the right leg. The plethysmogram of the left leg (Fig. 33A) shows clearly the auricular fibrillation, but is otherwise normal. That of the right leg (Fig 33B and c) is typical of a complete occlusion. Following intensive treatment recanaliza- tion of the embolus occurred, and when the patient was re-examined six months later (Fig. 34), the pulse volume was the same in the two legs.
Fig. 35 is reproduced to demonstrate the value of the plethysmogram in analyzing the effect of drugs on the peripheral circulation. Adrenaline, I: 500,000,
was given by the intravenous drip method. Simul- taneously with the plethysmogram, the respiration and the drops of the adrenaline solution administered are recorded. For the latter a photo- electric drop recorder (Goetz, 1948) has been developed which, when connected to the galvano- meter in our plethysmograph instead of the skin temperature thermocouple, will furnish a clear record of the drops administered, permitting detailed analysis of the effects of the drug on the peripheral circulation.
Apart from being employed in the solution of purely vascular problems, plethysmography is of g.reat value in the investigation of such changes in bodily and psychical functions as are reflected in the cardiovascular system. Ever since we first described our digital plethysmograph, we have demonstrated how an unexpected noise, a deep breath, a sigh. a ya\\'n. emotional stress, mental strain and apprehension are reflected in the plethysmog-ram. producing sudden vasoconstriction.
as judged by the diminution in pulse and digital volume a~sociated ,,·ith other well-known cardio- vascular reactions such rtS tachycardia. dyspnoea and a rise in blood pressure. Indeed. it could be demon- strated that the plethysmogram reflects changes in
432 S.A. MEDICAL J OURNAL 10 July 1948
vasomotor tone which are as yet insufficient to produce change in blood pressure or noticeable tachycardia. In 1943 we therefore wrote that plethysmography should prove a useful method of investigation to the psychologi t, and we may add
hould play an important role as an objective clinical method in psychosomatic medicine. Indeed,
SU~I ~1i\RY
Digital plethy mography as devi ed by u can no ionger be regarded as a purely experimental labora- tory method, but has been developed into a simple, clinical method by which routine examination of the peripheral circulation can be carried out, either at
Fig. 30. Venous congestion tests (first left toe) in a case of complete embolic obstruction of the popliteal artery.
A. During rest. B. Fully dilated.
Note hardly any difference in arterial inflow between A and B.
a beginning has been made by yan der Merwe and Theron (1947) who have demonstrated that our plethysmographic method can easily be employed in measuring emotional stability.
the patient's bedside, in the operating theatre, or in the laboratory. This has been accomplished by incorporating all the features of 'our earlier method in a portable plethysmograph.
10 Julie 1948 S.A. TYDSKRIF VIR GENEESKUNDE 433
FIG. 31.
-~he study o~ I?eripheral vascular disease is greatly asslste~ by cll~lcal plethysmography, which gives exact mformatlOn about the amount of organic occlusion, the degree of spasm and the development of the collateral circulation. Such information is of pri~e importanc~ J;>ecause the question of prog- nOSIS, and the pnnclples on which the treatment of these groups must rest, differ radically.
The plethysmographic appearances in the normal
~nd in the diseased are discussed and the portable plethysmograph is described.
I am indebted to the Editor of the American Heart Journal for permitting me to incl~de Figs. 2B, 13, 15, 18, 30 and 31 in this paper, and to the EdItor of the South African Journal of
iedical Sciences for Figs. 2A, 16 and 17.
The expenses of this research were defrayed by the Ja.cobus tephanus Marais Research Fund.
It is with pleasure that I record my thanks to the Honorary taff of the Groote Schuur Hospital for referring patients originally admitted under their care.
FIG. 31.-Venous congestion tests in a case with complete organic obstruction of main arteries.
A. During rest.
B. Fully dilated.
Note marked difference uetwecu the two in the absence of a11\' increase in pulse volume, in- dicating good collateral circula- tion.
Fig. 32. Equa~ arterial inflow ?n venous congestion in two cases, despite gross obstructIOn of main vessels in A, as judged by absence of pulse volume, indicating extremely good eollaters supply in A.
434 S.A. MEDICAL J OURNAL 10 July 1948
I am especially grateful (,0 Mr. H. Hall and Mr. J. Connor for their able assistance in building the portable plethysmo·
graph, and to Miss L. Commins and Jr. C. C. Goosen for help with the manuscript and the photography.
C:oetz.
Goetz, noetz, C:oetz,
R. H.
R. H.
R. H.
R. H.
(1939) (1939) (1940) (1942) :
Quarl. J. Exper. PhysioJ. 29. 239.
I bid. 29. 321.
Brit. J. Snrg. 27. 506.
Clin. Proc. 1. 190.
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...
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...
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Fig. 33. Plethysmograms of first right (A) and first left (B and Cl toes of a case with auricular fibrillation and embolic obstruction in left popliteal artery. A and C during full dilatation. B during rest.
REfERENCES
Bluntschli, H. J., and Goetz, R. H. (1948): Amer. Heart J. (In the press, June).
noetz, R. H. (1933) : Klin. Wchnschr. 44. 1717.
Goetz, R. H. (1935) : PfluegerJg Arch. 235. 271.
Goetz, R. H. (1943) : S. Afr. J. Med. Sei. 8. 65.
Goetz, R. H. (1945) : S. Afr. Med. J. 19. 91.
Goetz, R. H. (1946) : Amer. Heart J. 31. 146.
Goetz, 'R. H. (1948) : Lancet. 1. 830,
van cler Merwe, A, B., and Theron, P. A. (1947): J. Gen. Psycho!. 37. 109.
10 Julie 1948
j.'IG • .'>4.
S.A. TYDSKRIF VIR GENEESKUND!
Fig. 34. Same case as in Fig. 33, six montbs later.
A. First left toe.
R. First right toe.
Both during full dilatation. Compare B with Fig. 33C and note recanaliza·
tion.
~--~ . 435
~ - - -
-~
--
- -----
Fig. 35. Blood flow (fir"t right toe), respiration and drops of i.v. drip simultaneously recorded to demonstrate the effect of intravenous infusion of adrenaline 1:500,000 (following Lv. Dihydroergocornine) on the peripheral blood flow. Dr. = photo.
electric drop recording. Each notch represents one drop infused (18 drops per c.c.). Each drop contains 0.00000011 gm. of adrenaline.
