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small, but when the constriction has advanced to a considerable degree this portion assumes a comparatively larger size and has been very aptly compared to a small potato both in size and form. Pain is manifest after the disease has progressed to a certain extent, and becomes more marked as the depression grows deeper. This depression may begin either on the plantar surface or on the interdigital fold, and from there it gradually encircles the toe. It seems to be much more marked on the plantar than upon the dorsal surface. After continuing for a variable period of time, extending from three to twenty years (a case is reported wherein it had existed fifty years), spontaneous amputation takes place, either through accidental means,

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gangrene, or atrophy. Whatever the cause of this severance, relief is immediately experienced, and the subject of the trouble no longer has any difficulty in walking. A condition which I have observed in the specimen in my possession is one to which I have seen no allusion by any author. It consists in a marked change in the nail throughout its proximal half, there being cross and longitudinal furrows and a general roughness as well as thinning of the ungual structure. The general consistency of the toe is somewhat elastic and almost doughy; whereas at the line of constriction it has a somewhat firmer, fibrous feel which would suggest a hardening of those tissues; and the other, fatty degeneration.

There was at one time an impression that the little toe alone was

the seat of the disease, and Da Silva Lima stated in 1880 that up to 1867 he had no knowledge of the disease localizing itself in any other toe, and at the date he wrote he had only heard of five exceptions. A comparatively large number have been reported since, so that it may be stated in general terms that any toe may be affected. Not only this, but the manifestation may be unilateral or symmetrical, and one or more toes be the seat of the trouble. Cases have been reported in which all the toes of both feet were implicated. As has been mentioned above, the arm, the leg and the fingers have been said to be attacked, but much doubt has been expressed on this point and the cases reported have been looked upon rather as some sort of sclerosis than as true ainhum. Unfortunately, no microscopic examinations were made, and these, after all, are the only methods by which a definite conclusion could be reached and the true nature of the affection determined.

The seat of the constriction is said to be the digito-plantar fold. In some cases the metatarso-phalangeal joint is the one implicated. Walter L. Pyle states that no case has been seen at the base of the ungual phalanx. That it does occur at this locality does not admit of a doubt, as the specimen in my possession shows this quite plainly, and a reference to Figs. 1 and 2 will amply demonstrate the fact. This, in connection with the numerous published cases, would go to show that ainhum may occur at any of the articulations of the toes.

So far as the etiology of this affection is concerned, there does not seem to be any definite conclusion reached up to the present time. A cause assigned was the wearing of rings on the toes, a custom prevalent among many African and other tribes. That this might act as a causative factor to a certain degree is possible; but on the other hand, in India, where no such custom prevails, many cases are seen. Again, injuries to the feet from walking barefoot were supposed to be explanatory. The accidental picking up of a pebble between two toes was deemed a plausible explanation, but Da Silva Lima exploded this theory by reporting cases in individuals who habitually wore shoes. Others have confirmed this. A soft soil, a sandy soil and a hard soil have each in turn been regarded as a factor in the production of the trouble. None of these reasons can be justly invoked, and the conclusion to which we are driven is that ainhum is a disease sui generis whose exciting cause may possibly be pressure upon the foot occurring in an individual predisposed to the affection. The trouble is not congenital, as it has not been observed before the fourth year and generally makes its appearance between the ages of thirty and thirty-five. Moreover, males are subject to it in greater proportion than females. Heredity, which has been invoked as a cause, cannot

be proven; ainhum is not observed in successive generations, and it would be as logical to assume that it is confined to natives whose noses are particularly flat. Climatic influences cannot be invoked, as the disease arises under the most diverse climates so far as dryness and humidity are concerned. It has been asserted that because ainhum occurs in lepers it is a change induced by leprosy. This is a non sequitur, as a large proportion of the cases observed have been in individuals not affected with leprosy nor living in leprous districts. It has been observed that the affected individuals belong to races possessing a pigmented integument; no Caucasian has ever been seen suffering from ainhum, and this fact is sufficient to invalidate the claim that the disease is due to a micro-organism and is contagious. However, an examination into the pathology of the disease as well as its histopathology will throw more light upon the subject than mere idle speculation.

P. G. Unna has very justly deplored the fact that up to the present the histopathologic changes of ainhum have only been examined in the later stages of the disease, and, as a natural consequence, the course of the disease in its various stages has not been observed, so that we are not enabled to follow the process with that exactitude which would give us a definite knowledge of its course. Upon cutting a toe longitudinally it will be observed that the integument is much thickened, the adipose tissue being about normal. A large amount of fibrous tissue appears to be present. At the point of constriction the entire mass seems to be fibrous. Whilst the distal phalanx or phalanges are considerably enlarged, the proximal phalanx is atrophied. It is not a rare thing for the proximal phalanx to keep up the atrophic process after the distal portion of the toe has dropped off, and to finally disappear. If the bones of the toe be examined it will be found that they have undergone nutritive changes in the form of rarefying

A very good representation of these changes may be seen in Fig. 3, from a paper by Francis J. Sheperd. The other gross appearances which are sometimes found are: ulceration at the point of constriction, or scars following that process. In my specimen, changes in the nail may be seen, as has been mentioned above.

The more thorough and best description of the histopathologic changes observed in ainhum has been written by C. H. Eyles, who made a most thorough examination with the possible exception of the nerve alterations. From his rather meagre description of this portion. there can be but little doubt that the process is about the same as that observed in neuritis. Walter L. Pyle gives a very good summary of the findings of Eyles, which I will quote. He says: "In ainhum there is, first, simple hypertrophy, then active hyperplasia. The papillæ are

pushed down and deprived of blood-supply, and undergo horny change. Meanwhile the pressure thus exerted on the nervi vasorum sets up vascular changes which bring about epithelial changes in more distant areas, the process advancing anteriorly-that is, in the direction of the arteries. This makes the cause, according to Eyles, an inflammatory and trophic phenomenon due mainly to changes following pressure on vaso-motor nerves." To sum up, the trouble is a tropho-neurosis, and the various changes observed point to this as the only true solution of the pathogeny of the process. The fatty changes and fibrous formations point to this, as also do the osseous, in which we find the rarefying osteitis advancing in a regular manner from the periosteum but quite irregularly from the centre and with scarcely any attempt at any new bone-formation. This tropho-neurotic explanation is also in accord with observed facts. It is in the anesthetic form

FIG. 3.-Showing line of constriction and bone atrophy. (After Sheperd.) of leprosy that we find ainhum, and, as is well known, tropho-neurotic changes are there well marked and of a very strong character. In my specimen, taken from an anesthetic leper, we observe a further symptom of tropho-neurotic character, viz., the evident nutritive changes in the nail. In ainhum, hyperesthesia and anesthesia are observed the latter but rarely, still it is a sufficiently strong indication of a tropho-neurosis. The subject, however, requires more complete examinations of the disease in its various stages before a definite conclusion can be reached and matter formulated in such a manner as to preclude all possibility of doubt.

So far as the treatment of the affection is concerned, there is very little to be said. It is the same to-day that it was thirty years ago. In the vast majority of cases the cure, if such it may be called, occurs through spontaneous amputation. The constriction growing deeper

and deeper, and the distal portion doubling up under the foot, makes the gait unsteady, and this unsteadiness is increased by the pain. These conditions tend to make the individual strike the toe against obstacles, the distal portion is knocked off, and the ulcerated stump heals readily. In the earlier stages the disease may be arrested by making a free incision through the constricting band. When the disease has proceeded to its full development, nothing remains to be done but amputation, which is easily performed with the knife or scissors. As the progress of the trouble is rarely symmetrical in different toes, it not infrequently happens that the two different operations may be performed upon an individual at the same time.

The above is merely a bare outline of the description of a comparatively rare affection which has attracted a considerable amount of attention. To those who are desirous of following up the subject more closely some help may be afforded by the following:

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