SYMMETRIC GANGRENE

Synonyms.—Local asphyxia; Raynaud's disease; Fr., Asphyxie locale des ex-
trémités; Ger., Raynaud'sche Krankheit.

Definition.—An affection, usually of the extremities, of probably
trophic nature, characterized by local ischemia and asphyxia, which
usually terminate in the gangrene of the skin and underlying tissue.

While considerable irregular information was known as regards this
affection, Raynaud's³ description was the first well-defined presentation;
his contributions, with those of Barlow and others, have given a clear
portrayal of its clinical symptoms and behavior.

Symptoms.—The extremities, such as fingers and toes, the ears,
nose, and occasional other parts may be the seat of the disease. On

¹ Gussenbauer, Wien. med. Blatt, Feb. 2, 1899.

² C. S. Wallace, Lancet, Dec 23, 1899 (a record of 26 cases observed in a period
of eleven years in St. Thomas’ Hospital, London).

³ Raynaud, “De l‘asphyxie locale et de la gangrène symètrique des extrémités,”
These de Paris, 1862. Also paper by same writer, Arch. Gén. de Méd., 1874, vol. i, pp.
5 and 189. English translation in New Syd. Soc‘y publication, Selected Monographs,
1888, by Barlow, with valuable additional notes.

SYMMETRIC GANGRENE

433

the ears and nose, however, the gangrenous stage is rarely reached.¹
It is, generally, symmetric. The first symptoms² are, as a rule, cold­
ness and paleness of the parts—local ischemia; pain and numbness may
or may not have preceded. Sooner or later the second stage is reached,
that of local asphyxia, in which the parts become dark red, livid, and
bluish, and sometimes swollen, with not infrequently tenderness and
shooting pains. There may be, in either of these periods, a repeated
retrogression and reappearance for some time, and occasionally it does
not progress beyond the second stage. Finally, however, the condition
usually eventuates in gangrene, generally of a dry character; there may
be formation of vesicles or bullæ along the edge of the gangrenous
margin. Or, instead of gangrenous changes, the part affected,
especially if the fingers or toes, may gradually become atrophic,
withered, and indurated.

In many cases the process goes on until it reaches the beginning of
the third stage, that of persistent lividity, of bluish or bluish-black
color, and may remain in this state an indefinite time. Or in some
instances complete resolution may take place, to be followed by recurrent
attacks.

On fingers or toes the gangrene may involve considerable area.
It may be of a dry and mummified character, and gradually drop off;
or it may be cast off by underlying inflammatory and suppurative action;
or, instead of dry gangrene, it is of the moist character, with some puru­
lent infiltration of the subjacent tissue. The resulting ulcers heal slowly.

Etiology and Pathology.—The causes may be varied; in fact,
it is questionable whether Raynaud's disease is a distinct entity or
merely a symptom of many underlying affections. It has been ascribed
to many agencies: cold, exposure, general disturbance of nutrition, a
sequence or associated condition of severe systemic fever or disease,
nephritic disorders, and to various neuroses. In some instances malarial
fever seemed of etiologic bearing (Rey, Mourson, Fischer, Calmette and

¹ Fordyce, Jour. Cutan. Dis., 1896, p. 87, records a case in which the ear-tips alone
were affected and gangrenous.

² Bronson, “A Case of Symmetrical Gangrene,” Jour. Cutan. Dis., 1903, p. 456
(with case illustration), describes a peculiar case in which not only was the so-called
local syncope entirely lacking, but the usual situations were spared, the malady involv­
ing symmetric areas on the legs and ankles and clinically characterized by recurrent
attacks of pain and inflammation, exactly symmetric, together with the development of
a necrotic process; the author viewing the case as a possible transitional form between
Raynaud‘s disease and erythromelalgia.

In this connection the condition described under the name dermatitis symmetrica
dysmenorrhoica, by Matzenhauer-Polland (Archiv, March, 1912, and Oct., 1912, p. 185),
Kreibich (ibid., April, 1912), Friedeberg (ibid.), and Mathes (ibid., Oct., 1912) may be
referred to. The patients were dysmenorrhœic, with disturbances of the heart and
vasomotor systems, and often psychic abnormalities. The eruptive conditions, almost
always symmetric, and mostly nocturnal in appearing, consist of a moist dermatitis,
an urticarial erythema, or a spontaneous necrosis. It is usually ushered in with an
intense burning sensation, becoming later urticarial in appearance. It may go on to
vesicles and bullæ formation, and dry into brownish yellow crusts, which fall off and
leave stains. In some places there may result superficial necrosis. In the several
cases reported the sides of the face, arms, and legs and anterior aspect of trunk were
favorite localities. Both Kreibich and Mathes believe the lesions have an angioneurotic
basis; Friedeberg leans toward Freund‘s theory that pathologic alterations of metabolism
may result as a sequel to abnormal menstruation, and provoke the skin symptoms.
Self-production of the lesions was considered, but eliminated.

28

434                                      INFLAMMATIONS

Leloir, and others) ;¹ Osier,² in 9 cases observed by him, was not able to
confirm this in a single instance. An arteritis of syphilitic origin,
probably beginning peripherally, is, doubtless, as Jacoby³ has strongly
pointed out, responsible for some cases reported as examples of Ray-
naud's disease. It is doubtless in most instances of purely neurotic
origin—a vasomotor nutritive disturbance.

There is, first, a contraction of the arterioles and capillaries (Ray-
naud), which explains the first stage; this is followed by dilatation and
paralysis of the vessels, giving rise to the livid or blue color. It is alleged
by Weiss, however, that these later changes are due to a contraction of
the veins. At all events the local disturbance is a circulatory one, and
this may be due to peripheral or central causes. According to Leloir,
its most common subjects are between the ages of fifteen and thirty-
five, and four-fifths of them are females.

Diagnosis and Prognosis.—The symmetric character of the
disease and the sites affected, together with its course, are sufficiently
characteristic.

The outlook for permanent recovery is not very favorable. Some­
times recovery takes place after one attack. As a rule, however, and
even in seemingly favorable cases, there are likely to be recurrences,
or one part after another may become involved. If it is possible to
recognize the etiologic factor, and this be susceptible of removal, a per­
manent cure may result. In unfavorable cases, septic infection may
gradually ensue.

Treatment.—The recognition of the underlying causative factor
is all-important for a result. Treatment is, therefore, somewhat different
in different cases, although in the most it is probably empiric. As a rule,
invigorating treatment, especially directed toward the nervous system,
and a full generous diet and attention to hygiene will have an influence.
Remedies having an action upon the peripheral circulation, such as amyl
nitrite, and nitroglycerin, and others have been advocated but are of
questionable value. Inhalations of oxygen have also been advised. A
method of treatment commended by Raynaud, which in some instances
seems to be of decided service, is that by the galvanic current with the
positive pole applied at the fifth cervical vertebra and the negative over
the last lumbar vertebra or over the sacrum; the current should be
moderately strong, and continued for five to ten minutes daily. The
negative electrode, with weaker current, can also be applied to the affected
region. Application of the faradic current to the parts should also be
employed from time to time.

In the earlier stages cold application, frictions with stimulating lini­
ments, and massage are of service. Later, the local treatment is essen­
tially antiseptic and surgical.

¹ Calmette, Gas. médicate, 1876, No. 44; Leloir, “Diseases of Skin,” Twentieth
Century Practice, vol. v, p. 807.

² Osier, Johns Hopkins Hosp. Bull., Feb., 1900.

³ Jacoby, “ A Contribution to the Diagnosis of Raynaud's Disease,” New York Med.
Jour., Feb. 7, 1891 (with a good bibliography); see also paper (3 cases) by H. H.
Morton, Jour. Cutan. Dis., 1894, p. 249, and the paper (with illustrations) by Howard
Fox, Med. Review of Reviews, May, 1907, and Jour. Cutan. Dis., Aug., 1907.

But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy!

Also, please consider sharing our helpful website with your online friends.