April 6, 1895. THE HOSPITAL.

Progress in Medicine. DISEASES OF THE . firmed by a similar examination, and believes that tbere are one occurs as above in re- (Continued from page 460, Vol. X VII.) two varieties ; (I.) thinks that gurgitation, and the other (II.) which is merely a species Significance of Symptoms.?Huchard1' " of the anacrotic with the second wave rounded brady-diastole" or prolongation of the diastole and does itself in is a sign of most serious import when occurring beginning high, actually present stenosis. Even the true anacrotic is shown in cerebral hajmorrhages, comatose states, and pulse by Steell25 not to be indicative of and the arterial degenerations. The cause of inorganic always stenosis, P. bisferiens has been observed where there was no in- insufficiency of the mitral valve ia referred by to a of Mahomed's. Dombrowski13, not to dilatation of the orifice, but to competence according paper The condition of the blood in the of displacement of the papillary muscles, which prevents cyanosis congeni- disease has been various observers. closure of the valve. Romberg, however, insists that tal heart analysed by Banholtzer26 found in one case that the this is contrary to the known action of those muscles.1' haemoglobin stood at 160 cent, of normal, and the red cells at A new diagnostic sign in anaemia is announced by per in of A. Morrison-7 Verstraeten20 in the presence of a de diable just 9,450,000 place 5,000.000. the were 110 below the inferior border of the liver, and about three- gives two others in which figures and 92 cent, for and quarters of a centimetre to the right of the median per cent, per hcemoglobin, the and and he line. It is produced in the inferior vena cava, and corpuscles 8,470,000 6,700,000, quotes similar from other writers. He believes occurs in anaemia, but not in hepatic cirrhosis. The instances be too to be accounted for signs of dilatation of the right ventricle are discussed the increase to great by by S tacey W ilson21. The ch ief dilatation in adolescence concentration of the blood, but that it is in a sense occurs upwards and to the left, so that the pulmonary compensatory. The corpuscles being insufficiently their functions and wear and tear valves may be under the first interspace, and the oxygenated, are individual duration is ventricle may extend to the left nipple line in the lessened, and their so number becomes second space. Some rotation of the heart takes place increased, that their total The increase occurs not at the same time, so that the apex often appears in the much greater than usual. where fourth space external to the nipple line. In later life only in congenital cases, but also in others rare case of the dilatation may extend a little to the right of the cyanosis is present. A very pulmonary sternum, as well as upwards. The signs are pulsation incompetence occurring in adult life and confirmed in second and third left interspaces and in the post-mortem is recorded by T. Oliver.28 The diastolic of the neck, while the is in the fourth space ; murmur was conveyed down the left of the sternum increased area of dulness; a pulmonary systolic to the apex of the right ventricle, while the pulse was murmur; accentuated second sound bruit de diable, not that of aortic regurgitation. Cyanosis, distended of were also signs tricuspid regurgitation ; and a bruit de galop. veins in the neck, and profuse epistaxis Several of these signs may be absent. noted. Another case of interest29 is one of embolic A discussion on the significance of an accentuated pneumonia, caused by endarteritis of the pulmonary second sound has been carried on by Ringer and , which was associated with congenital stenosis. Fear, Ewart, and others. The two former show Shingleton Smith who reports the case, remarks that that a high tension causes a loud second sound, but right and its resulting embolic pneumonia that it also occurs sometimes in the opposite condi- are well recognised, while the arteritis was probably tion, and that various factors affecting the thickness localised at this spot by the existing contraction of the and density of the overlying tissues may influence its vessel. production.22 In short, that there is great difficulty The Physics of the Circulation.?The effect of gravity in explaining its production in any given case. on the circulation if all the vessels were re- Ewart23 argues that the pulmonary second sound is laxed, would, of course, render the brain blood- singularly limited in its area of conduction, while a less in the upright position. Hence an exact co- sound from the aorta is heard far and wide over the ordination must be maintained between the con- cardiac area and beyond it, as shown by the anatomical tractile forces of all the vessels and the pressure due to configuration of the parts. The rare pulsus bisferiens gravity. In a paper before the Royal Society Leonard (as well as the anacrotic one) has been usually regarded Hill showed that this constant compensation is effected as produced by . It is defined as follows : by the splanchnic vaso-motor mechanism.30 When this ''Both percussion and tidal waves are well repre- is damaged by , asphyxia, or chloroform the sented, but the latter, instead of being rounded and cerebral circulation ceases. Chloroform paralyses sustained, forms a sharp angle, Moreover, the second this compensatory mechanism more rapidly than ether, wave begins low, and the two waves reach the same hence the danger of elevating the head in chloroform level or nearly so. The dicrotic wave follows, and its narcosis. Probably, too, emotional syncope is due less degree of development varies." Now G. Steell has to heart failure than to paralysis of the splanchnic given reason to think that this pulse may occur nerves. In short, when this protective agency ceases without aortic stenosis, but rather in regurgita- to act, the blood at once accumulates in the veins and tion. J. Mitchell Clarke describes an undoubted the lowest part of the body. case where imcompetence but no stenosis was Brunton, in the Harveian oration, carefully discussed present on post-mortem examination. He also re- the mechanics of the muscular circulation.31 The blood the ports*4 two other cases in which the pulse occurred supply may be principally sent to either the skin, without any evidence of stenosis though uncon- intestinal tract, or through the muscles, by vaso-motor 10 THE HOSPITAL. April 6, 1895. regulation. Muscular contraction, while it compresses is a morbid susceptibility to cold, which pro- the vessels of that muscle, leads to dilatation of those duces paroxysmal closure of the ; gangrene vessels by stimulation of the vaso-dilator nerves. Thus may occur in the paroxysms. (2) Symmetrical gan- gentle exercise may lead to general dilatation of the grene of the extremities, acro-sphacelus, with nothing vessels and lowering of blood pressure, since the vessels paroxysmal about it, and complete recovery of the of the muscles can easily contain all the blood of the circulation after a single attack. (3) Cases in which body, while violent exercise by compressing the vessels the skin passes into a condition of diffuse scleroderma. may raise pressure. Again, in the latter case the Here again is a tendency to paroxysms and gangrene, stimulation of the nerves from the muscles to the but these are merely complications of the scleroderma. heart vastly increases its rate, thus again raising the In true Raynaud's disease there is no such change in pressure. Hence the pain produced by sudden exertion the skin. The best remedy for the pure disease is the habitual use of small doses of in a weak heart, whereas continued and especially very opium. Another is described Levi35 as It can gentle exercise by dilating the vessels of the muscles type by purely hysterical. be ameliorated by but tends to recur. renders circulation more The of this hypnotism, easy. bearing There is often a of rheumatic exercises in previous history fever; physiology on massage and graduated the onset is sudden, and often accompanied by heart disease is obvioua. urinary disturbances, such as polyuria. It is one of the vaso-motor of and Raynaud's Disease-*-M-orton discusses3^ three cases, phenomena hysteria, gangrene sometimes takes Some cases of ainhum are the etiology of each of them being different from the place. described by H. De Brun. A toe is gradually detached others. In one the terminal would at first phalanges without pain, haemorrhage, or sore, by a constriction at turn white, while the re3t of the hand was livid. the digito-plantar fold. The fifth toe generally Eventually this became permanent, and gangrene of is the first to go, and others follow, there is a phalanx followed. This, he thinks, was pure vaso- diminished temperature in the limb, some swelling and some disturbances and loss of knee motor spasm. In the second there had long been in- lividity, sensory and the character found in terstitial Acute in the occurred, jerk, paroxysmal nephritis. pain fingers Raynaud's disease. It nearly always occurs in the with and The arterial lividity, finally gangrene. coloured races. Angiopathic gangrenes must, accord- fibrosis was probably the agent here. The third ing to Lancereaux, be carefully distinguished from patient had syphilis some years previously, the angio-neuroiic.37 The former are marked by severe nerve after which fingers were white and the hands livid, while the nails pains for years beforehand, morti- fied or occur, which never termi- were more or less degenerated. The syphilitic cause patches phlyctense nate in moist gangrene. Raynaud's disease he looks was shown the under by improvement specific upon as a special form of gangrene due to some remedies. Urquhart33 describes two cases in insane usually undetected form of intoxication. The influence persons where the feet were attacked, where neither of cold and other agencies in producing functional neuritis or vascular occlusion, but rather a central spasm is, he thinks, exaggerated. 17 13 nerve lesion seemed to be the in which it Am. M.S. Bullet., Sept. 1. Int. Med. Mag., July. 19Fort3oli. only way 21 der Med., p. 554, 1894. 20A. J. Med. Sc., Nov. Binning. Med.. could be He would neuritis as Rev., Sept. 1. 22 Lancet, Sept. 29. 23 Lancet, Oct. 6. 21 Deo. produced. regard 25 Lancet, 29. Lancet, Nov. 24. 26 B.M.J., July 7. 27 Lancet, Jan. 5, 1895. rather than causal. J. Hutchinson34 28 29 30 secondary points B.M.J., July 7. B.M.J., Aug. 17. Lancet, Jan.5, 1895. 31 B.M.J.. 32 33 out that there are three which must be dis- Oct. 20. Int. Med. Mag., July. Lancet, Jan. 5, 1895. 31 Olinioa, types 35 36 J.,Nov. 28. Laucet, Dcc. 1. Med. Week, Sept. 28. 37 Med. Week! tinguished : (1) True Raynaud's disease, where there J une 25.