1384 SCOTLAND.-PARIS

SCOTLAND

(FROM OUR OWN CORRESPONDENT)

EMBOLISM IN THE LIMBS

Sir Thomas Lewis, F.R.S., delivered the GeorgeAlexander Gibson lectures of the Royal College ofPhysicians of Edinburgh last Monday and Tuesday.His title was Symptoms and Signs of Embolism inthe Limbs with Special Reference to Pain. He beganby describing the changes which develop in a limbafter complete occlusion of the blood-supply with atourniquet. The limb immediately becomes slightlypale ; then a stage of cyanosis develops ; and thisin turn is followed by reappearance of pallor, whichincreases. The temperature of the limb falls slowly.If the muscles of the limb are kept at rest there islittle or no pain ; but if they are exercised, severepain develops in those that are being used. This

pain is due to an accumulation of products of meta-bolism and disappears in two or three seconds ifthe circulation is re-established. The blood whichrestores the circulation must be oxygenated if it isto bring relief. When the limb is kept at rest afterocclusion of the blood-supply the first disturbancenoticed is that there is some loss of the sense of touchat the finger-tips. This analgesia slowly spreads upthe limb from the periphery, at the rate of about5 cm. per minute. True anaesthesia to light touchdevelops in the same way, and with it position-sensebecomes lost. Muscular power disappears also atthis stage. In the upper extremity the small musclesof the hand are first affected ; the extensors of thewrist then become weak, and finally the flexors losepower. The ability to appreciate pain and tempera-ture is lost at a later stage. Examination of limbsthat have been amputated shows that the pilomotorresponse is preserved even longer. Sir ThomasLewis has been able to prove that the effect on thenerves is caused neither by an effect on the end-

organs, nor by pressure on the nerve, but by loss ofthe blood-supply to the nerve. The longest nervesto the ends of the extremities are the most vulnerable,as they also appear to be in cases of peripheralneuritis.

In his second lecture Sir Thomas discussed thecause of the pain which occurs in clinical cases ofembolism of the main arteries of the limbs. He

explained that the theory commonly accepted wasthat the pain arises at the moment the vessel isblocked and is due to some local effect on the wallof the artery. This explanation, he believes, cannotbe accepted. Numbness and paralysis of the affectedlimb are often present, it is observed, by the timepain appears, and the site at which the pain is feltis often distal to the position of the embolus.Obstruction of the abdominal aorta, for example,first causes coldness and numbness in the legs andlater paralysis and pain felt in the legs, not in theabdomen. Re-establishment of the circulation byoperative removal of an embolus at once relievespain in the limb just as it was relieved, in the experi-ments, by removal of the tourniquet. The lecturerreferred to a case in which an embolus was dislodgedfrom the axillary artery and settled at the lower endof the brachial artery. This event gave completerelief from pain in the arm, though the radial pulsedid not return. The blockage of a blood-vessel inthe brain or lungs causes no pain, but if a vessel isblocked in a muscular organ, such as the heart orgut, pain is a striking feature of the disturbance

produced. Sir Thomas Lewis concluded, therefore,that the pain caused by embolism of a large arteryto a limb develops at an interval after the blockage,and is always associated with ischsemia of the tissuesof the limb. The tissue primarily concerned in theproduction of this pain is, in all probability, themuscles.

A NEW DERMATOLOGICAL DEPARTMENT

On June 5th Sir Norman Walker opened the newdermatological and venereal diseases department ofthe Edinburgh Royal Infirmary. The building,which has cost 40,000, has five floors and a basement.The venereal diseases department occupies the lowerthree floors, while the third and fourth floor form theskin department. Included in the building is pro-vision for 38 in-patients in the venereal diseasessection and 46 in-patients in the skin diseases section.Sir Norman Walker said that John Hughes Bennett,who became professor of physiology in 1848, was thefirst to teach dermatology in Edinburgh. Beds werefirst set aside for skin disease in the Infirmary in1891 and the opening of the new eye department in1905 enabled cases of skin diseases to be admittedto Ward 2. He considered that the new departmentwas the best in the country. Besides the 46 bedsavailable, there are also 90 for diseases of the skin atthe Western General Hospital.

PARIS

(FROM OUR OWN CORRESPONDENT)

OUTBREAKS OF PINK DISEASE

A RECENT communication by Dr. Rocaz of Bor-deaux to the French Academy of Medicine seems toindicate that infantile acrodynia has lately been

quite common in the South West of France. Sincehe reported his first case in 1926 he has observed68 similar cases himself, and has been informed of90 others observed by colleagues about whose diag-noses there could be no doubt. If to these 158 casesbe added other known cases that Dr. Rocaz hasbeen unable to check and the doubtless numerouscases escaping recognition, the total must run intoseveral hundreds. The geographical distribution

suggests that there are several more or less densecentres of this disease, in each of which some 20 to30 cases have been observed. Other minor centreshave been responsible for some 10 cases each. Thedistribution of the disease would seem to correspondto that of other diseases conveyed by carriers ; andin two of the main centres, infantile acrodyniaseemed to follow the course of important waterways.Most of the children were aged 1-3 years, and therewere few cases above the age of 6. The sexes wereequally involved, and the distribution of the casesthroughout the different seasons of the year was mostirregular. It may perhaps be significant that thecentres in which this disease was most commonwere also those which have suffered much from otherneurotropic diseases such as encephalitis and polio-myelitis. The occurrence of more than one casein the same family suggested infection; in one

family, a brother and a sister developed typicalinfantile acrodynia at the same time. In another

family one child developed and recovered fromacrodynia that overtook another child 20 monthslater, born in the interval. In a third family, a childdeveloped the disease 3 months after having beenin contact with a cousin who was suffering from it.