system it becomes evident that disturbances of vascular tone may be
produced by many different causes acting upon many various parts. They
may be due to local affections of the part in which the symptoms are
present, as in the case of erythema[22] after burns or frost-bite, or
congestion of any organ after injury. They may be due to affections of
the vaso-motor nerves passing to the part affected, as in the case of
vascular changes due to peripheral nerve lesions.[23] They may be due
to affections of the sympathetic ganglia connected with the part
affected, as in the case of migraine,[24] sudden flushing of one ear,
certain cases of polyuria,[25] and Basedow's disease.[26] They may be
due to lesions in the spinal cord affecting the vaso-motor centres[27]
or compressing the nerve-roots on their way to and from the
sympathetic ganglia,[28] as is the case in the various forms of
myelitis and in Raynaud's disease or symmetrical gangrene, and in
meningitis, tumors of the cord, or Pott's disease. They may also be
caused by such conditions in the cord as cut off the vaso-motor
centres from the medullary centres, such as transverse myelitis from
compression or traumatism.[29] They may be due to lesions of the
medulla oblongata,[30] as is seen in some cases of polyuria and
glycosuria,[31] and in cases of universal erythema[32] following acute
fevers. They may be due to diseases of the cerebral hemispheres, as is
evident from the vaso-motor symptoms occurring in hemiplegia and
hysteria. Finally, they may be of a reflex {1252} origin, dependent
upon some obscure source of irritation in a part quite distant from
the region in which the symptoms appear.[33]
[Footnote 22: Vol. IV. p. 511.]
[Footnote 23: Vol. V., “Neuritis.”]
[Footnote 24: Vol. V., “Migraine.”]
[Footnote 25: Vol. IV., “Polyuria.”]
[Footnote 26: Vol. III. p. 761.]
[Footnote 27: Vol. V., “Syringo-myelitis.”]
[Footnote 28: Vol. V., “Meningitis Spinalis.”]
[Footnote 29: Vol. V., “Transverse Myelitis.”]
[Footnote 30: Vol. V., “Medulla.”]
[Footnote 31: Vol. I., “Diabetes Mellitus.”]
[Footnote 32: Vol. IV. p. 512.]
[Footnote 33: Vol. V. p. 205.]
The DIAGNOSIS of the seat of the lesion in many cases of vaso-motor
neurosis may be made if the organ or the exact limitation of the area
affected be ascertained, and the history of the case, together with
the concurrent symptoms of other kinds, be considered. In some cases
no organic cause can be found, and in these a reflex cause should be
diligently searched for.
SYMPTOMS.—A vaso-motor affection may manifest itself either by a spasm
or a paralysis of the vessels. In angiospasm the part affected becomes
pale, and irritation no longer causes a vaso-motor reflex. It looks
shrunken, and if the skin over it is loose it may be thrown into folds
or shrivelled, presenting the appearance seen in the hands after long
immersion in hot water. The lack of blood in the part arrests the
processes of metabolism which are normally constant, and if the
condition continues this may result in such a disturbance of nutrition
that ulceration, or even gangrene, may ensue. The local anæmia,
combined with the cessation of metabolism, produces a fall of
temperature in the affected part, which is then more easily affected
by the temperature of the air than in a normal state, so that exposure
to cold is very liable to cause freezing. These conditions necessarily
produce an impairment of function, so that if the affection is located
in the extremities, as the fingers, they are soon rendered useless.
The term digiti mortui has been applied to this state. In the surface
of the body angiospasm causes cutis anserina, pallor, numbness,
tingling, slight anæsthesia, and analgesia. If it occurs in a limb,
the finer motions are imperfectly performed, and in time the nutrition
of the muscles may be so impaired as to produce atrophy and paresis.
It may even lead to gangrene. Nothnagel has recorded[34] five cases of
sciatica in which the pain produced a reflex spasm of the vessels of
the leg, which, persisting, resulted in partial paralysis, atrophy,
lowering of temperature, pallor, and sensory disturbances. Ross
mentions[35] the sudden appearance of circumscribed patches on the
hands and forearms of washerwomen, in which there is a pallor,
coldness, and partial anæsthesia. These may be limited to the
distribution of a single nerve, and may be accompanied by trophic
affections.
[Footnote 34: _Arch. f. Psych._, v.]
[Footnote 35: Vol. I. p. 221.]
Spasm of the veins may occur as well as of the arteries,[36] or
independently of them. In the latter case the blood will not pass out
of the capillaries. The part will then be blue, swollen, œdematous,
and painful; the temperature will be lowered by increased radiation of
heat, and all the sensations and functions be impaired in greater or
less degree. If this continues, nutrition may suffer, and in the end
gangrene develop, which will take its course and lead to the throwing
off of the part. Grainger Stewart has described such a condition
occurring in both hands and feet.[37] It may be likened to a severe
form of Raynaud's disease.
[Footnote 36: Weiss, “Symmetrische Gangrän,” _Wiener Klinik_, 1882.]
[Footnote 37: Grainger Stewart, _An Introduction to the Study of
Nervous Diseases_, p. 138.]
Angio-paralysis is more frequent than angiospasm, and may be due
either to paralysis of the vaso-constrictors or to excitement of the
vaso-dilators. It shows itself by a bright-red or mottled appearance
of the skin, and increase of local temperature, and more rapid
processes of {1253} nutrition, together with an increase of secretion
if the part is a gland or a mucous membrane, and an increase of sweat
if it is the skin. In the latter case an increased sensitiveness to
changes of temperature, a subjective sensation of heat, and
hyperæsthesia and hyperalgesia may occur. The hyperæsthesia on the
paralyzed side which is present in hemiparaplegia spinalis is ascribed
to the vaso-motor paralysis. But these symptoms soon give place to
others. The dilatation of the vessels, which at first caused an
increased flow of blood to the part, produces a slowing of the
blood-current in the part, just as a river runs less rapidly where it
becomes wider. The slowing of the current in the skin allows of a more
complete cooling of the part as the radiation of heat and the
evaporation of moisture are increased, and the slowness of the renewal
of blood impairs the processes of nutrition, so that to the first
stage of redness, heat, and increased metabolism there ensues a stage
of blueness, cold, and defective nutrition, and the function of the
part may be impaired. In this stage it usually presents a mottled
appearance, and may be slightly swollen and œdematous, and the
continued increase of perspiration gives it a clammy coldness to the
touch. In all of these conditions severe pain, sometimes of a burning
character, is a very distressing symptom (causalgia). These conditions
are seen in peripheral nerve-lesions, and give rise to the appearances
which have been so admirably described by Weir Mitchell.[38]
[Footnote 38: _Injuries of Nerves_.]
A peculiar combination of symptoms may be mentioned here, to which
Weir Mitchell has given the name of erythromelalgia.[39] This disease
begins with tenderness and pain in the soles of the feet, which are
soon followed by a marked distension of the capillary vessels. The
congestion is attended by a sensation of burning pain similar to that
produced by a blister. The surface is at first of a dull dusky-red
color; later it appears purple. The redness is not uniformly
distributed over the sole, but occurs in patches of irregular shape,
being especially frequent over prominent parts exposed to pressure and
friction, and the attacks seem to be brought on by long standing or
walking. At first there is a rise of temperature in the affected
surface, the arteries pulsate visibly, the veins are swollen, and
there may be some œdema. Later, the foot is cold and pale. Sensations
of touch and temperature are normal, but the part is so extremely
tender that walking is impossible. There is no paralysis. One or both
feet may be affected, but the patches of redness are rarely
symmetrical. The hands are occasionally affected. The condition may
occur in paroxysms or may remain for some time. It resists all known
methods of treatment, although applications of cold relieve the
burning pain to some extent and the tenderness enforces rest.
[Footnote 39: _Amer. Journ. of the Med. Sci._, July, 1878.]
With angio-paralysis may be classed the taches cérébrales of Trousseau
no longer considered diagnostic of meningitis, but denoting a weakened
condition of vaso-constrictor action in the local ganglia of the
vessel-wall which may occur upon local irritation of the skin in any
severe disease affecting the nutrition of the general nervous system.
Actual rupture of the capillaries in the course of vaso-motor diseases
is rarely observed, although the stigmata appearing in hysterical and
cataleptic patients may be ascribed to this cause. In this connection
tabetic ecchymoses may be mentioned, which appear suddenly without
local injury, {1254} and resemble an ordinary bruise, running a
similar course. They occur only in the course of locomotor ataxia.[40]
[Footnote 40: Straus, _Arch. de Neurologie_, tome i. p. 536.]
In addition to these forms of vaso-motor affections there is a
condition of instability of vascular tone which manifests itself by
sudden transient changes in the circulation of various organs. This is
a functional affection, usually due to malnutrition. It is seen in
many cases of neurasthenia and hysteria, and manifests itself by
sudden flushes or pallor, alternations of heat and cold, local
sweating, attacks of mental confusion, and inability to use any organ
continuously from disturbance of the power of the vaso-dilators to
maintain a condition of functional hyperæmia.[41] Little is actually
known about the causes of this state of the vascular system, although
much has been written about it. (For a fuller description the article
on Neurasthenia may be consulted.)
[Footnote 41: Anjel, _Arch. für Psychiatrie_, xv. 618.]
Many functional derangements of the internal viscera have been
ascribed to such vaso-motor instability with more or less
probability,[42] but hypothesis of this kind, however plausible, is
evidently beyond confirmation. It is especially in affections of this
kind that causes of reflex irritation are to be carefully sought.
Cutaneous angio-neuroses, such as have just been described, may affect
any part of the body. They usually appear suddenly, producing much
discomfort and an impairment of function in the part if it is an
extremity. They disappear as rapidly as they come. The duration of
such attacks varies from a few minutes to several days. They are very
liable to recur. If it is the vessels under the control of the
cervical sympathetic which are affected, the symptoms will be those of
migraine or of lesion of the ganglia.[43] If it is the vessels in the
extremities which are involved, the condition of digiti mortui or
erythromelalgia or symmetrical gangrene[44] may be produced.
[Footnote 42: Fox, _The Influence of the Sympathetic System in
Disease_, London, 1885.]
[Footnote 43: See p. 1263.]
[Footnote 44: See p. 1257.]
A singular epidemic occurred in France in 1828 and 1830 which was
termed acrodynia. Many persons were suddenly seized with vomiting and
purging, and soon after the onset the extremities became red or
mottled in blotches, swollen and œdematous, and hot, painful, and
tender. The attacks lasted from a few days to two months, and during
this time the skin became thick and hard, the muscles weak and subject
to spasms, and the general health was impaired. Relapses occurred in
many cases, but all finally recovered, and hence the exact nature of
the disease was not ascertained.
COURSE.—In any case of vaso-motor neurosis the course of the disease
and its termination will depend chiefly upon its cause. If the cause
is some permanent lesion of the nervous system, the condition will
remain, and in this case the termination will depend upon the severity
of the symptoms. Angiospasm may be so severe as to lead to gangrene
ana the separation of the part affected, or may be so slight as to
cause only subjective discomfort and a little pallor. Angio-paralysis
may lead to an extreme degree of congestion, which is attended by heat
and pain at first, later by paræsthesia and coolness, with increased
liability of the part to be affected by changes in the surrounding
air. This stage is succeeded by one of less marked dilatation of the
vessels and a spontaneous partial {1255} recovery, although the more
moderate symptoms may continue indefinitely and seriously impair the
function of the part. If the cause is a temporary derangement of
function in the vascular mechanism, is reflex irritation which can be
removed, or is a curable organic disease, the symptoms will subside
rapidly or gradually and perfect recovery may follow. If the condition
is one of irritability in the vaso-motor centres, producing
alternations of flashing or pallor, such as is observed in nervous
exhaustion, it may recur irregularly for a considerable length of time
until the causative condition can be removed.
PROGNOSIS.—The prognosis must be determined in each case by a
consideration of the cause of the affection, of the nature of the
symptoms, of the severity of the disease, and of the possibility of
success in both symptomatic and causative treatment. In the
angio-paralytic cases an eventual spontaneous relief from much of the
discomfort may be promised, although the duration of the symptoms
cannot be predicted.
TREATMENT.—Treatment must be directed primarily to removing or
diminishing the severity of the cause. A review of the section on
Pathogenesis will indicate how wide a field this may include, and the
reader must be referred to the special articles which are alluded to
in that place for therapeutic measures. Special diligence is to be
shown in searching for a source of reflex irritation. When the cause
cannot be reached, and when the symptoms are of such severity as to
demand immediate attention, treatment may be directed to them.
In all conditions of vaso-motor disease it is important to shield the
part from external injury; for if the vessels are dilated they are
liable to rupture, and any abrasion of the surface may produce serious
inflammation and ulceration; and if the vessels are contracted any
injury will be repaired slowly and imperfectly on account of the
anæmia, and may even hasten the approach of gangrene.
Perfect rest, bandaging with cotton, and even the application of a
light splint to the extremities will be advisable in cases of
angiospasm. It is desirable to retain the animal heat, inasmuch as its
supply is deficient. In angio-paralysis rest in a somewhat elevated
position and applications of mild evaporating lotions are indicated in
the early stage; later, the limb may be bandaged. It is not advisable
to attempt by tight bandaging to counteract the effect of the vascular
paralysis, for the nutrition of the limb is liable to suffer and
gangrene may be induced.
Massage of a part affected with vaso-motor symptoms is of great
service, since the circulation can be increased in the veins, and thus
indirectly in the capillaries, and the nutrition of the part can thus
be favored. It is more efficacious in angio-paralysis than in
angiospasm. Too rough rubbing is of course to be avoided, lest the
skin be injured. All counter-irritation is to be strictly forbidden.
Electricity has been used with varying results. According to Erb,[45]
moderate faradic applications contract the vessels; strong faradic
applications, especially with the brush, dilate the vessels. The
galvanic current at first contracts the vessels, but this is followed
by a secondary dilatation, which will be greater and occur more
rapidly the stronger the current used.[46] Cathodal closures contract
the vessels; the anodal {1256} continuous current dilates them widely.
Stabile continuous currents through a nerve dilate the vessels which
the nerve supplies. Inasmuch as vaso-constrictors and vaso-dilators
pass together in many nerves, and are found together in all parts, it
is impossible to apply electricity to either alone. In those cases,
therefore, in which it has been ascertained which set of vaso-motors
is affected, it is not always possible to produce a direct effect upon
that set by electrical treatment. Erb recommends, in conditions of
vaso-motor spasm a trial of the galvanic current, the cathode on an
indifferent point, the anode being applied over the vaso-motor centres
governing the part, and also over the area of the body which is
affected, and held there while a moderate continuous current is
passing, interruptions being avoided; or, the cathode being placed on
the neck, the anode may be applied to the nerves passing to the
affected part; or a strong continuous current may be sent through the
nerve, its direction being changed several times during a moderately
long application. Finally, the faradic brush applied to the part or a
strong faradic current sent through its nerve may relax the spasm. In
any case, all these methods should be tried before electrical
treatment is abandoned.
[Footnote 45: _Electrothérapie_, 562.]
[Footnote 46: To this statement Lauder Brunton assents—_Pharmacology_,
p. 250.]
In vaso-motor paralysis other methods are used. The cathode is placed
on the part congested, and a weak galvanic current is employed with
frequent interruptions or even with changes of the pole; or the
cathode may be moved about upon the reddened skin while a mild
continuous current is passing. A very weak faradic current with wet
electrodes, or even a weak faradic current applied with a brush, may
be of service. Here, again, various methods may be tried.
If the extremities are affected, it may be well to immerse them in a
basin of water which is connected with one pole of the battery, and
the current directed in the manner just described, according to the
case. It must be confessed that no definite results can be predicted
from the use of electricity in these cases, and much more experience
is needed before definite rules can be laid down. The records show
that in apparently similar cases opposite methods of application have
produced favorable effects, while in other cases all methods have
failed. Too much reliance should not be placed in electrical
treatment. Erythromelalgia is an obstinate affection, and symptomatic
treatment, directed chiefly to quieting the pain by opium and allaying
the sensation of burning by cool baths, must be resorted to.
Internal remedies may be tried appropriate to the condition present.
In angiospasm nitrite of amyl inhaled, or nitro-glycerin 1/100 gr.
t. i. d., may give considerable relief, although both of these drugs
are to be used with caution. Chloral hydrate is also of some service,
and where the patient is in pain and suffers from insomnia this may
fulfil several indications. In angio-paralysis ergot has been used
with advantage. Oxygen inhalations are of service. Chloride of
potassium may also be tried. It is evident, however, that such
remedies, acting as they do upon the general arterial system, are not
to be depended upon in the treatment of local conditions, since they
have no selective action upon the affected part. The majority of the
drugs known as sedatives and antispasmodics have been used in these
conditions, but the records of individual cases show that they are not
of much avail. Theoretical therapeutic measures based upon {1257}
experimentation on animals have been fully discussed by Lauder
Brunton,[47] but practical experience has not yet been sufficiently
extensive to warrant any further statements.
[Footnote 47: _Pharmacology, Therapeutics, and Materia Medica_, pp.
229-360. Lea Bros., 1886.]
Symmetrical Gangrene.
SYNONYMS.—Local asphyxia, Asphyxie locale, Raynaud's disease;
Symmetrische Gangrän.
DEFINITION.—Symmetrical gangrene is an affection of the nervous system
characterized by arterial or venous spasm appearing in symmetrical
parts of the body, especially in the phalanges of all the extremities,
which may result in trophic changes or in gangrene. There are various
stages in the disease, which have given rise to the various names by
which it is known. The stage of local syncope, in which there occurs a
moderate contraction of the arterioles and consequent pallor of the
part, may be followed by a stage of local asphyxia, in which the
complete contraction of the arterioles cuts off entirely the supply of
arterial blood, and the regurgitation of venous blood produces
cyanosis of the part; and this, if continued, may result in the
gangrene of the part, which is then thrown off. Instead of a condition
of local asphyxia, there may be a spasm of the smaller veins,
resulting in a local erythema, which may go on to capillary stasis and
then to gangrene. The spasm of the vessels may cease at any stage as
suddenly as it began; and if this occurs in the first or second stage,
no gangrene results.
HISTORY.—While isolated cases of this affection had been recorded as
curiosities during the past two centuries,[48] the disease was first
studied with care by Raynaud in his _Thèse de Paris_ in 1862. He
collected twenty-eight cases which had been described with accuracy or
had been personally observed in the hospitals of Paris, and after a
thorough analysis of the symptoms defined the disease as “a neurosis
characterized by an exaggeration of the excito-motor power of the cord
presiding over the vaso-motor nerves.” He called particular attention
to the condition of spasm in the vessels, and proposed the name
asphyxie locale to designate the peculiar appearance of the parts
affected. He also noticed the resulting gangrene as a new variety of
gangrene, not dependent upon embolism or upon changes of an
atheromatous nature in the coats of the vessels.
[Footnote 48: Schrader, 1629; Hertius, 1685; Bouquet, 1808; Moulin,
1830; Racle, 1859—cited in full by Weiss, “Symmetrische Gangrän,”
_Wiener Klinik_, 1882.]
The condition was at once recognized by others, and several cases had
been reported prior to 1873, when Raynaud published a more complete
article on the subject in the _Dictionnaire de Médecine et de
Chirurgie_ under the title gangrene symmétrique; in 1874 he recorded
five new cases in the _Archives générales de Médecine_, vol. i. pp. 5
and 189.
The disease, having been thus established as a definite nervous
affection, began to be noticed in other countries than France; and
Billroth in Vienna,[49] Weir Mitchell,[50] Mills,[51] A. McL.
Hamilton,[52] and J. C. Warren[53] {1258} in this country, and many
other careful observers, published cases, together with more or less
complete articles upon the disease. In 1882, Weiss produced a
monograph[54] upon the subject containing references to all the cases
which had appeared; and this is still the most complete article to be
found, although the essay of R. Lauer[55] and the discussion of the
disease by the Berlin Medical Society,[56] as well as the short
articles of Schulz[57] and Lutz,[58] deserve mention, for they contain
additional observations of cases and numerous facts not to be found
elsewhere.
[Footnote 49: _Wiener Med. Wochensch._, 1878, No. 23.]
[Footnote 50: _Amer. Journ. of the Med. Sci._, 1878, July.]
[Footnote 51: _Ibid._, 1878, Oct.]
[Footnote 52: _N. Y. Med. Journ._, 1874, Oct.]
[Footnote 53: _Boston Surg. and Med. Journ._, 1879, No. 3.]
[Footnote 54: Weiss, _Wiener Klinik_, 1882, “Symmetrische Gangrän;”
also _Zeitschrift für Prac. Heilkunde_, 1882.]
[Footnote 55: _Inaug. Dissert._, Strasburg, 1884.]
[Footnote 56: _Zeitschrift für klin. Med._, vi. p. 277, 1883.]
[Footnote 57: _Deut. Arch. f. klin. Med._, xxxv. 183, 1884.]
[Footnote 58: _Bäyr. ärzt Intell. Blatt_, 1884, xxxi. 24.]