51 Ibid., 1878, Oct.
52 N. Y. Med. Journ., 1874, Oct.
53 Boston Surg. and Med. Journ., 1879, No. 3.
54 Weiss, Wiener Klinik, 1882, “Symmetrische Gangrän;” also Zeitschrift für Prac. Heilkunde, 1882.
55 Inaug. Dissert., Strasburg, 1884.
56 Zeitschrift für klin. Med., vi. p. 277, 1883.
57 Deut. Arch. f. klin. Med., xxxv. 183, 1884.
58 Bäyr. ärzt Intell. Blatt, 1884, xxxi. 24.
SYMPTOMS.—The disease begins suddenly in all cases, and the constitutional symptoms are less prominent than the local ones. In some cases there are noticed a certain degree of mental disturbance, a condition of depression with a tendency to sigh and cry without cause, disturbed sleep with unpleasant dreams, irritability, and headache. A loss of appetite and disorders of digestion may follow, and then the local symptoms appear. In other cases, which seem to be the majority, the local condition develops without any such premonitory disturbances of the nervous and digestive systems, although these may ensue. The local symptoms first noticed may be paræsthesiæ or pain in all the extremities, usually limited to the tips of the fingers and the toes. These are continuous and severe, and are immediately followed (and occasionally preceded) by an appearance of ischæmia or of cyanosis or of erythema, in the order of frequency named.
(1) The fingers may look pale and dead, presenting the appearance of the so-called digiti mortui, and may be cold, painful, and anæsthetic. If this condition is moderate in degree, a certain amount of blood will continue to flow through the contracted arterioles, and then it corresponds to the description given by Raynaud of syncope locale. If it is extreme, the part may be wholly deprived of arterial blood, and then a true local asphyxia is present. In this stage the patients usually suffer considerably, although some do not complain of pain until the next stage. The ischæmia is attended with an impairment of sensation to touch, temperature, and pain, and finer motions become clumsy on account of the subjective numbness and actual anæsthesia. At the same time, the fingers look shrunken, the skin being thrown into folds, as if the hand had been soaked in hot water, or they may appear as if frozen, the skin being hard and immovable.59 The secretion of perspiration may be increased, and the fingers feel damp as well as cold, or it may be suspended. The local temperature is lowered. If the part is cut, little or no blood will flow. At this stage the arterial spasm may suddenly relax and the part return gradually to its normal condition, the cessation of the constriction of the arteries and the return of blood being usually accompanied by burning pain, which may last for some hours. The duration of such an attack may vary from a few moments to several days. If it continues longer, this stage is usually succeeded by the second stage, of cyanosis.