the phenomena of algidity occur; one step further and the symmetrical gangrene is produced. In order to understand how this algidity may be confined to one set of vessels, for instance, those of the upper or lower limbs, it is only necessary to suppose a central irritation occurring at a single point in the cord from which the vaso-motors of the particular region affected happen to emerge. This may be limited to a single finger of each side. It now remains to determine the way in which this irritation is supposed to act. The vaso-motor nerves are affected not only by direct irritation, as in the experiment alluded to, but may be also susceptible to reflex action. An example of this is the contraction of the vessels of one hand when the other is suddenly plunged into very cold water. A similar action is the sudden pallor produced in the face by severe pain inflicted upon some distant point. In the disease we are now considering it is probable that a similar chain of events takes place. Inasmuch as this disease appears after confinements, or may show itself periodically at the menstrual epoch, it is but reasonable to suppose that the reflex irritation may take its origin in the uterus. In a later article on the subject, Raynaud defines this disease as "a neurosis characterized by an exaggeration of the excito-motor power of the cord presiding over the vaso-motor nerves," and he advises the application of "constant descending currents" to the spine. The excito-motor power of the cord is thus weakened, and the reflex contractions of the vessels. are in consequence diminished. A consideration of the reflex origin of this vaso-motor disturbance would suggest occasional phenomena, such, for instance, as are observed in traumatic inflammations, supposed to be due to reflex actions brought about by irritation of the cerebro-spinal nerves, and, in fact, we find this to be the case. Vulpian 2 has described, in connection with the above disease, a symmetrical congestion of the extremities which he considers as similar to the congestion of the skin seen in certain cases of neuralgia. It is possible, he thinks, that a sort of symmetrical neurosis of the peripheral nerves of the extremities occurs, causing by reflex action dilatation of the vessels of the parts. In using the term vaso-motor neurosis we must accept it in this sense only. The seat of the pain is in the sensitive nerves or in the tissue occupied by them, and the dilatation of the vessels secondary. Based on this mode of action is the theory of one observer that neuralgia of the ileo-lumbar nerve brings on congestion of the uterus and its appendages, and that metrorrhagia and leucorrhoea may be thus produced. This view is certainly plausible, and the supposition had already oc 1 Archives générales de Médecine, 1874, page 5. 2 Leçons sur l'Appareil vaso-moteur. Vulpian. Paris. 1875. * Cahier des Nevroses vaso-motrices (Archives générales de Médecine, 1863). curred to me whether certain fleeting and capricious uterine pains, brought on frequently by emotional perturbations solely, might not be explained by a vaso-motor disturbance of the uterine vessels. The changes seen in the tongue in Dr. Mills's case, presently to be mentioned, are suggestive of such possibilities. "A young, very anæmic man, without apparent cause, had first gangrene of the tip of the nose, then of both feet. After suffering for months he died; as on the patient, so on the cadaver, I could find nothing morbid beyond the excessive, inexplicable anæmia." Recently Dr. Medopil 2 reported a case under Billroth's care. The patient was a female, nineteen years of age. She was first seen by Dr. Billroth in September of the year previous. She then noticed that the fingers became dead and pale after washing in cold water. The tip of the index finger of the right hand soon became very painful, remained hard for a time, and finally mortified. The gangrene terminated in necrosis of the ungual phalanx. The middle finger of the same hand was next attacked with inflammation resembling paronychia, which did not extend beyond the radial half of the bed of the nail, and terminated in the exfoliation of small, dry, parchment-like crusts. A year later the index and middle fingers of the left hand were similarly affected, at this time all the fingers of each hand being cold and pale. Dr. Charles K. Mills reports a case of "vaso-motor and trophic affection of the fingers," which evidently belongs to the chronic and recurrent form of "local asphyxia," and which he believes to be unique: The patient first noticed the symptoms of local syncope at the age of nineteen. The little finger suddenly became cold, white, and numb. Later, one or more fingers would on exposure to cold present a frost-bitten appearance. "The disorder persisted, growing gradually worse, until the ends of all her fingers and both thumbs were more or less involved." Six months later a small swelling formed at the point of the right thumb, which felt as if a splinter had run into it; a small abscess resulted. "Similar abscesses appeared from time to time in all her fingers and the other thumb." These recurred at intervals of two or three months. The first attack in each case caused great pain. When the patient came under Dr. Mills's care, in June, 1878, nearly four years after the first symptoms, there was a decided blueness of the finger tips. Once after dancing the tip of her tongue became bluish-white, and felt as if it had been burned with hot tea or coffee. Her troubles were always exagger ated by emotional disturbances. There was a presystolic murmur and signs of a cavity at the right apex. A careful series of thermometrical observations showed the temperature of the fingers to be considerably below the normal. The author gives a large number of interesting minute observations, but I think I have made selections sufficient in number to show the identity of the affection with the one we are now considering. Under the head of Chronic Vaso-Motor Hyper-Irritation, Dr. A. M. Hamilton describes an affection due to a 66 temporary spasm of the muscular coats of the small vessels of some limited spot, the site being usually a part of the hand." "The peculiarity is the limited blanching and coldness coming on without assignable cause, and finally subsiding, 1 Wiener medizinische Wochenschrift, No. 23, 1878. 2 Surgical Pathology, page 302, first American edition. 3 American Journal of the Medical Sciences, October, 1878. 4 New York Medical Journal, 1874. to reappear perhaps after an uncertain interval," the fingers being chiefly affected, "evidently our local syncope." Dr. S. Weir Mitchell 1 gives a collection of cases illustrating a form of vaso-motor neurosis of the extremities, to which he gives the name erythromelagia (eruthros, red; melos, a member; algos, pain). The first series of three cases is described quite at length, and would probably be classified by Vulpian with those cases described by him as symmetrical congestion; indeed, one of Vulpian's cases is quoted. The patients were males, and the affection chiefly confined to the feet. The earliest symptom was a burning pain in the soles, especially on standing, and also a flushing of the part. The flushing is thus described: "In the graver examples the area of greatest pain in the soles or hands is distinctly and permanently marked by a dull, dusky, mottled redness, as if the smaller vessels were always over-distended." In the erect position"the foot gets redder and redder, the veins stand out in a few moments as if a ligature had been tied round the limb, and the arteries. throb violently for a time, until at length the extremities become of a dark-purplish tint." Treatment was not attended with very satisfactory results. Dr. Mitchell is inclined to consider these and other cases which I shall presently allude to as an unrecognized type of spinal or cerebral disorder, possibly associated with distinct lesions of definite regions. His fourth case is a fair example of the disease we are considering. The patient was a merchant, twenty-nine years of age. The symptoms, briefly, burning pain in the cushions of fingers of left hand, later of right hand; finger ends darkly congested; at times similar pain in the feet; had had syphilis; no benefit from treatment. His sixth case is a still more striking instance: The patient was a woman, a Mexican, and was treated by Dr. Stillé, of Guerrero. She was twenty-nine years old; no organic disease; burning of tips of fingers of both hands on palmar aspect; fingers clubbed, nails thickened. "It seems as if the muscular and fatty portions had shrunken, and also as if the last phalanges had been absorbed.” The next case was that of a baker, twenty-two years of age. The symptoms were similar, but we noticed that he had in addition rare pustules on the hands, the agony caused by which seemed to be intense. A case quoted from Sir James Paget is evidently one of local asphyxia, brought on apparently by excessive use of cold baths. It is quite evident that many of Dr. Mitchell's cases belong to the group of "local asphyxias," and that some are, on the other hand, "symmetrical congestions." Dr. T. A. McBride reported last spring to the New York Neurological Society a case of digiti mortui, and is the only American writer whom I have consulted who distinctly recognizes the relation of this affection to local asphyxia and symmetrical gangrene. 1 American Journal of the Medical Sciences, July, 1878. Fischer1 reports two cases, one following intermittent fever. The cheeks, ears, and nose were the parts affected. The patient was a man forty-two years old. A second case followed an attack of typhus fever. The writer gives several theories as to the origin of the disease, but inclines to that of Raynaud. A case, reported by Christian, of gangrene of both feet, following malarial fever, deserves to be mentioned in connection with these cases. Drs. Stewart and Holton 2 report a case of symmetrical gangrene caused by chronic endarteritis, the name being obtained from Ziemssen's Cyclopædia, Vol. VI., page 383, evidently not due to local asphyxia. Dr. Bernard Henry describes a case of idiopathic gangrene of the four extremities, which, if not a specimen of the symmetrical disease of Raynaud, certainly merits mention here: The patient was a widow, forty-two years of age. She had led a very dissipated life, and had been treated for syphilis; had given birth to nine children, besides having had frequent abortions intentionally produced. She first noticed after washing a stinging sensation in the hands and feet. They were rendered more painful by scratching, and soon assumed a dusky red color. When first seen the disease was thought to be purpura. In the course of two weeks the affected parts turned black and mortified. These were the hands and forearms for about a third of their length, and the lower third of the legs and feet. The tip of the nose and the skin over both patella and the cartilages of the ears were of dark hue, and finally sloughed. There was great aversion to warm coverings. The gangrenous portions became mummified. The parts separated, and some were removed, but the patient died at the end of about two months. At the autopsy it was thought that there was some tendency to fatty degeneration of the heart, and apparently mitral stenosis; there was commencing cirrhosis. A case very similar to this is reported by Dr. Thomas Camp 3 under the title, A Case of Supposed Ergotism. Both legs, all the fingers, the ala of the right nostril, and the upper part of the helix of each ear were the parts affected. There was a peculiar eruption coming and going on different parts of the body. The patient eventually recovered. Ergotism was suspected in both of these cases, but there was no direct proof. The following references are obtained through the kindness of Dr. J. S. Billings from the Index of the National Medical Library at Washing ton: Fischer. Arch. f. klin. Chir., Berlin, 1873, xviii., page 335. Schonba. Hospitals Tidende Kjobenharr, 1869, iii., page 17. Favre. Gaz. des Hôp., Paris, 1874, xlvii., page 347. Bull. Norsk. mag. f. Luegevidensk, Christiania, 1873, iii., page 695. Le Fort. Bull. Soc. Chir., Paris, 1872, third series, i., page 178. Padieu. Bull. des Tran. Soc. Med., Amiens, 1868, vii., page 66. Jaccoud. Jour. de Med. et de Chir. prat., Paris, 1875, xlvi., page 198. Gelabert. Indep. Med., Barcelona, 1872-3, iv., page 283. . Under Gangrene affecting both Extremities, not called Symmetrical, see Christian. Va. Med. Monthly, 1876, ii., page 199. Bishop. Clinic, Cincinnati, 1873, iv., page 25. Henry, Med. Examiner, Philadelphia, 1856, xii., page 129. Rademaker. Louisville Med. News. 1876, i., page 183. 1 Medical Record, May 11, 1878. 2 Chicago Medical Journal and Examiner, December, 1878. RECENT PROGRESS IN OBSTETRICS. BY W. L. RICHARDSON, M. d. 1 The Etiology of Face Presentations. - Dr. Mayr gives some interesting facts relating to face presentations. Out of 14,519 deliveries 0.73 per cent. were of the face, and 0.103 per cent. were of the brow. The relative number of first positions of the face to the second was as 1.4 to 1. The mean duration of the first stage of labor in primiparæ was 23.6 hours; in multiparæ 14.5 hours. The mean duration of the second stage was in primiparæ 12.5 hours, in multiparæ 1.26 hours. Rupture of the perinæum occurred in only seven cases out of one hundred and seven face presentations which were under his observation in the Munich Lying-In Hospital, but it happened in none of those in which the forceps had been used. Of the one hundred and seven mothers eleven suffered subsequently from some puerperal disease. Four patients who were delivered with forceps had later an attack of puerperal peritonitis, and three died; the result in the fourth case was unknown, the patient. being removed from the hospital while dangerously ill. The general mortality in the Munich Hospital was 1.7 per cent., while that of face presentations was 2.8 per cent. As regards the children, fifty-two were male, and fifty-five were female. Of these 6.54 per cent. died during or shortly after delivery. As regards the etiology of face presentations Dr. Mayr was convinced that the greater the weight of a child in proportion to its length the more readily a face presentation is produced. There is also an excessive prolongation of the occiput and an increased maximum transverse diameter. Part of this may be produced during the delivery, but not all of it. The unusual length of the antero-posterior diameter, when compared with the maximum diagonal diameter, is a well-known characteristic of heads in cases of face presentation. Owing to this excessive projection of the occiput the leverage of resistance applied to the occiput is increased, and the heads so delivered had an increased biparietal diameter. The head is then grasped tightly at the brim in the biparietal diameter; its axis of motion, as regards the pelvis, will be therefore at this point, which is further back than usual, and the expulsive contractions of the uterus will cause the extension of the head, which produces the face presentation. Treatment of Cracked Nipples. - Dr. Haussmann reports 2 two cases in which he had treated cracked nipples with a solution of carbolic acid. Every two or three hours dressings soaked in a two per cent. solution of the acid were applied to the nipples. At first a solution of the strength of five per cent. was used, but it was found that the 1 Archiv für Gynäkologie, xii. 2. 2 Berliner klinische Wochenschrift, 14, 1878. |