part produced the ptomains or toxins which poisoned the blood. This fact, numerous bacteriological experiments had proved. Alluding to its prevalence in the autumn, he pointed out that the constant occurrence of intestinal catarrh and gastric troubles at this period produced that amount of epithelial proliferation and lowering of the vital resistance in the intestines favourable to the invasion of the bacilli.

That this intestinal catarrh was a constant precursor and accompaniment of the disease was long ago pointed out by Murchison. Added to this, the increased growth of the bacillus on the fermenting intestinal contents, resulting from this proliferation, and the generation of their chemical toxin during growth, made the intestinal glands-always easily choked like all adenoid tissue when attacked by bacilli-fall an easy prey.

This infiltration of the glands of the intestine by the typhoid bacillus runs its course in the first fortnight of the disease from the onset of fever, and this was the normal length of typhoid from the pathological point of view. Pus-producing micrococci now invade the necrotic tissue, and from this period forward the disease is only one of septicemia due to the toxins they produce. The character of the typhoid temperature after the second week shows this to be the case.

We must therefore regard two forms of bacteria as playing a part in the course of enteric fever-the typhoid bacillus in the early stage and the suppurative micrococci in the latter stages. This fact suggested antiseptics as the most rational method of treatment in addition to suitable diet.

The gaseous form of antiseptics seemed to him the most thorough and suitable, as it permeated the tissues and entered the blood; and of these chlorine gas held first place, administered in some alkaline medium that would part with it readily in the intestines. One-fourth of the cases treated in this manner ended their fever on the fourteenth to the sixteenth day—a result which could not be achieved by any other method. A resolution that the discussion on Dr. Boyd's paper should be postponed until the next meeting having been proposed by Dr. N. FALKINER, seconded by Dr. C. F. MOORE, and carried,

The Section then adjourned.

CLINICAL RECORDS.

Notes on Uncommon Forms of Skin Diseases. By R. GLASGOW PATTESON, M.B., Univ. Dubl.; Fellow and Member of Court of Examiners, Royal College of Surgeons in Ireland; Surgeon in Charge of the Skin Department, St. Vincent's Hospital, Dublin.

VI, SYMMETRICAL GANGRENE OF THE EXTREMITIES (" RAYNAUD'S DISEASE"). THE affection of the extremities-feet, hands, ears, and tip of nosewhich goes by the name of Raynaud, is still sufficiently obscure in its pathology to allow us to group it, provisionally, at least, along with those cutaneous affections which are characterised by the phenomena of necrosis; and as the features which first led to its recognition as a morbid entity are those of a limited and usually superficial gangrene affecting the most peripheral parts of the body, we may be allowed to consider it here under the heading of rarer forms of skin disease.

CASE.-Mary W., aged twenty-two, a parlourmaid, came to St. Vincent's Dispensary on the 22nd of October, complaining of a "deadness in her hands." Exactly twelve months previously she first began to suffer from "dead fingers," and up to that time her health had been fairly good. She had had one or two slight attacks of bronchitis, and five years previously had suffered from an attack of rheumatism lasting six weeks, which she believed to be rheumatic fever, but which, at any rate, had left no appreciable heart damage. About a fortnight before the first attack of numbness of the fingers came on, she received a severe shock, being left alone in the house at night and fancying she heard it being broken into by burglars. She was very nervous and felt out of sorts for about a week, but afterwards felt as well as before. At this time she was suffering from some menstrual irregularities—at first amenorrhoea, and afterwards too frequent periods with very scanty discharge-which continued for about six months, when she went under medical treatment, and has since been practically well. The history of the onset of her affection is as follows:

About a fortnight after the shock above referred to, she awoke one morning to find one of her hands "asleep," and concluded she had been lying on it. The fingers from the first inter-phalangeal joint down were white, and quite numb and stiff, like "dead fingers," but instead of disappearing quickly this condition persisted for some little time, the natural "Continued from the number of this Journal for September, 1891. Vol. XCII. No. 237, p. 244.

colour being then gradually restored with slight pain and tingling. At this time she had a good deal of sewing to do, and she now occasionally found her fingers getting quite numb and powerless while so occupied. Shortly after this-from about the middle of November, 1890-she suffered from constantly-repeated attacks, which came on after rising in the mornings, or in the evenings when it got cold, or during the day on washing her hands in cold water or bringing them in contact with any cold substance. The sequence of events was always the same: at first, pallor and deadness, with a numb feeling in the fingers, which, after persisting for a variable time, was succeeded by a sharp tingling pain, with swelling and lividity of the extremities of the fingers, which became of a dark, greyish-purple colour. In these attacks the pallor and numbness ("local syncope") affected all the fingers equally from the first inter-phalangeal joint, but the second stage of pain and congestion ("local asphyxia") affected principally the terminal phalanges, the little fingers of both hands always escaping. At this time severe darting pains about the shoulders and down the forearms often preceded the onset of the local manifestations. About the middle of December the paroxysms became much more frequent, and were excited by the least exposure to cold, so that now the fingers were constantly swollen and dark in colour, and most of the time excessively painful and tender. For the relief of this poultices were applied, with the result that, though the pain disappeared, blisters containing clear serum formed over all the terminal phalanges, except those of the little fingers, followed by desquamation of the skin and complete shedding of the nails. Small ulcerations were left after the separation of the dead skin at the tips of the fingers just beneath the free edge of the nails; and this condition remained unchanged for some time, associated with a swollen and extremely sensitive state of the fingers, so that she was quite unable for any heavy work. It was not until June of the present year that they had quite returned to their normal condition, and even during the summer attacks of local asphyxia could be at any time induced by immersing the hands in very cold water. The attacks, however, were very slight, and she was quite able for her work without any distress.

In October, however, with the onset of colder weather the pains and numbness returned, though not with the same severity as before. The fingers are now affected chiefly in the mornings and evenings, less frequently during the day; and the attacks also differ in an important particular from those to which she was formerly subject, in that the stage of "syncope" is now absent, or so transient as to escape notice, and the pain, swelling, and blueness are the features that first arrest her attention, not as previously the pallor and numbness. The fingers when I first saw her were in this condition: they seemed somewhat swollen but were not adematous, were a peculiar slaty-blue colour, not the livid purple of

ordinary venous congestion, and were slightly painful, though sensation was everywhere normal, and they were not tender on pressure. The scars left by the previous ulceration on the tips of the index, middle, and ring fingers of both hands presented a cracked surface, and were apparently on the point of breaking down into small ulcers. There was no history obtainable of ague or hæmoglobinuria-conditions which have been associated with the affection in a certain number of cases.

While a patient in the hospital a various remedies, based on the supposed pathology of the disease, were tried by Dr. M'Hugh; but the measure of success obtained was limited and transitory. This has also been the experience of all previous observers. In order to appreciate the rationale of the measures adopted it will be necessary here to briefly review the pathological theories which have been put forward to explain the essential phenomena of the disease.

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In Raynaud's original thesis, published in 1862, he refers the phenomena to a condition of "capillary spasm," which occurs in subjects who are characterised by a nervous predominance." "In the simplest cases," he writes, "those in which the malady remains, if I may so say, in a rough state, the exaggerated peristaltic contraction of the capillaries drives the blood before it, the extremities become pale, withered-looking, and insensible. This is the dead finger.' But this phenomenon does not persist long enough for gangrene to follow. To contraction succeeds relaxation, the circulation is re-established, and everything returns to the normal state after a period of reaction more or less painful. Such is local syncope, in which the muscles participate in the contraction of the arterioles. Local asphyxia is only a more advanced condition. After an initial period of capillary spasm there occurs a period of reaction; but it is incomplete reaction. The vessels which return first to their primary calibre, or even beyond, are naturally those which present in their structure the fewest contractile elements-viz., the venules. At the moment when these are opened, the arterioles being still closed, the venous blood, which had been at first driven back into the great trunks of the dark blood system, flows again into the finest vascular divisions, and then the extremities will take on that tint, varying from blue to black, which is a certain index of the presence of venous blood in the capillary network. . This state may be chronic, and the spasm of the vessels may only have a limited duration, so as to return in irregular or intermittent attacks. Finally, it may happen, although much more rarely, that the capillary spasm comes on all at once with an intensity and a duration altogether extraordinary. Syncope and local asphyxia succeed one another rapidly. The venous blood becomes insufficient to

a The girl was admitted, November 3rd, into St. Vincent's Hospital, under the care of my colleague, Dr. M'Hugh, and by his kindness I was enabled to show her at the Dublin Biological Club, and to obtain the notes of her case while under treatment.

nourish the parts; the colour becomes deeper and deeper; small bloodstained infiltrations take place through the walls of the venules; these walls may themselves become granular; in one word, there is confirmed gangrene, and gangrene which may go on to the fall of many ends of fingers or toes." a In a paper, embodying subsequent researches, published in the Archives Génerales de Médecine, January, 1874, Raynaud carried his pathological theory a step further back to the central nervous system, and sums it up as follows:-"I would say that in the present state of our knowledge, local asphyxia of the extremities ought to be considered as a neurosis characterised by enormous exaggerations of the excito-motor energy of the gray parts of the spinal cord which control the vaso-motor innervation." b Based upon this theory was his plan of treatment by continuous descending electrical currents applied over the vertebral column, so as to act directly on the cord, one pole—the positive-being placed at the nape of the neck, and the other-the negative-over the lumbar enlargement, in combination with the application of the constant current directly to the extremities affected. In this way, Raynaud says, "the action exercised by the current in the cord appears to consist in an enfeeblement of the excito-motor power, whence there results a corresponding relaxation of the reflex vascular contractions," and so, applied during the stage of asphyxia, the occurrence of the consecutive gangrene may be prevented. In a valuable paper on the subject (Illustrated Medical News, Vol. III., 1889, p. 178), Dr. Thomas Barlow speaks highly of the value of what may be called the "electrical bath" method of treatment during the continuance of the paroxysm. "The blue extremity may be submerged in a basin of lukewarm salt and water, and one pole may be placed in the water and the other moved about on the limb above the level of the water. The current should be rapidly reversed, made, and broken, and the patient should be encouraged to make voluntary flexions and extensive movements of the limb during the time that it is being galvanised. This should be persevered with till the colour of the extremity has become quite red. . The galvanism and shampooing should be done at least once a day until substantial improvement is obtained, and then this should be maintained by the patient's own shampooing. Lamp baths, vapour baths, or, if they can be got, Turkish baths, should be tried. Diffusible stimulants are of doubtful benefit, and so are narcotics."

The theory of vascular spasm receives a certain amount of support from two of Raynaud's cases in which marked visual disturbances accompanied the peripheral paroxysms. In the first case "the patient affirms that his sight is good in the two eyes during the attack, but that during

"Selected Monographs." Raynaud on "Local Asphyxia." New Sydenham Society's Translation. 1888. P. 144.

Loc. cit. P. 182.