Leo Buerger: The Vascular Pathologist and His Saga of Thromboangiitis Obliterans

Thromboangiitis obliterans (TAO), also known as Buerger’s disease, remains the first diagnosis in case of a limb ischemia by many physicians, irrespective of having other risk factors, and are labeled and offered treatment in the same line worldwide. More than a century-old name for a limb ischemia still continues to be in the mind of every physician. TAO or Buerger’s disease goes with the name of Leo Buerger, who first confirmed the diagnosis histopathologically in the amputated legs due to ischemia. This was the real start in diagnosing and treating cases of limb ischemia and the beginning of a new era in vascular surgery. Although there were several reports in the mid-1800s describing patients with conditions resembling TAO, most lack pathologic confirmation or are confounded by the possibilities that the patient suffered from the sequelae of frostbite or arteriosclerosis.[1] von Winiwarter, a student of Billroth at the University Clinic in Vienna, is generally credited with the first convincing description, published in 1879, of a patient with TAO.[2] He performed and carefully documented the results of an autopsy on a man with a 12-year history of chronic leg ischemia culminating in “spontaneous gangrene” and limb loss. Histologic examination demonstrated extensive small arterial and venous occlusions marked by hypercellular thrombus and preservation of the internal elastic lamina. In 1908, Leo Buerger, working at Mount Sinai Hospital in New York, reported the results of detailed pathologic examinations performed on 11 amputated limbs.[3] He described the typical clinical picture of these patients with “presenile spontaneous gangrene” due to a distinct process he termed TAO. The patients were characteristically men with limb ischemia beginning between the ages of 20 and 40 years. They had absent ankle pulses, frequent attacks of limb coolness, blanching and pain, and months or years of trophic disturbances with eventual gangrene requiring major limb amputation. Pathologically, he identified striking perivascular inflammation of distal lower extremity arteries, veins, and nerves, which were often agglutinated in a fibrous, inflammatory process. The transition from normal to diseased artery was characteristically abrupt. Acute lesions contained giant cell foci in the vessel wall; however, as von Winiwarter noted, the internal elastic lamina was intact. Buerger subsequently published a book in 1924 entitled, The Circulatory Disturbances of the Extremities, in which he described long-term personal observations in 500 patients he had serially examined and followed.[4] An interesting historical coincidence is that Buerger was born in Vienna in 1879, in the same city and in the very year of von Winiwarter’s initial case report. Buerger’s thorough description, accurate characterization, and detailed pathologic studies of patients with TAO resulted in the attribution of the eponym Buerger’s disease, still the most widely used term for the condition in the 21st century. Leo Buerger (September 13, 1879–October 6, 1943) was an Austrian American pathologist, surgeon, and urologist and born in Vienna into a Jewish family, who immigrated to the United States when he was seven (either in 1886 or 1887) [Figure 1]. He attended several elementary schools in New York, Chicago, and Philadelphia. Buerger matriculated to the City College of New York, where he earned a B.A. in 1897, followed by studies at the College of Physicians and Surgeons, the medical school of Columbia University, where he obtained both his M.A. and M.D. in 1901. He developed his surgical skills in Breslau, Germany (now Wrocław, Poland) in 1905–1906. There he studied urology and simultaneously developed a special interest in arterial diseases.His contribution towards arterial diseases, is still considered as one of the remarkable milestone in the vascular surgery.Figure 1: Leo BuergerInitially, Buerger practiced at the Lenox Hill Hospital (1901–1904), then the Mount Sinai Hospital (1904–1905), and then as a volunteer in the surgical clinic at Breslau with study visits to Vienna and Paris. From 1907 to 1920, Buerger worked as a pathologist and surgeon at Mount Sinai Hospital. In 1908, he gave the first accurate pathological description of TAO or Buerger’s disease, a disease of the circulatory system associated with smoking, and is a progressive, nonatherosclerotic, segmental, inflammatory disease that most often affects small and medium arteries of the upper and lower extremities. In 1924, he described his eponymous test for lower limb ischemia (Buerger’s test). It involves the observation of color changes of the foot during elevation and lowering of the lower limb.[5] He is credited for many other developments in the field of vascular pathology. Aside from discovering Buerger’s disease and Buerger’s test, he authored the book Circulatory Disturbances of the Extremities [Figures 2 and 3]. He is also credited with developing the Buerger’s exercises or Buerger–Allen exercises, which were later modified by Arthus Allen. The exercises intend to improve lower limb circulation. The legs are held at 45°–90° until the skin blanches. They are then lowered below the level of the rest of the body at 90°. Finally, the patient is laid flat in bed. Typical times for each step are 2–3 min in an elevated position, 5–10 min dependent, and then flat on the bed for 10 min.Figure 2: His paper on Buerger’s diseaseFigure 3: Buerger and his scientific contributionHe was a prolific writer, and Published more than 160 articles in various scientific journals. Buerger wrote contributions to differentiate streptococci and pneumococci, reported on the therapy of tetanus with the new tetanus antitoxin and even dabbled in the area of blood transfusions. He also devised an operating cystoscope in 1910, as well as other urologic instruments. Buerger died at his residence at the Sherry-Netherland Hotel on Fifth Avenue and 59th Street in Manhattan after a 2-week illness. Buerger’s disease, or thromboangiitis obliterans, currently lacks definitive, specific management guidelines,hence it is essential to strengthen basic research as well as clinical trials to standardize management in this type of patient, since it is a disease with high impact on quality of life. At the same time, it is important for the present generation to revisit Buerger’s disease and remember the significant contribution of Leo Buerger in the field of vascular surgery. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.