MORVAN'S DISEASE; WITH THE CLINICAL REPORT OF A CASE.Read before the Chicago Medical Society. March 2, 1891

ARCHIBALD CHURCH
1891 Journal of the American Medical Association (JAMA)  
The first description of the diseased state which by courtesy and for convenience may be called " Morvan's disease," was made by Dr. Morvan, of Lannelis, in Brittany, and published in the Gazette hebdomidaire de Medicine et de Chirurgie in 1883, under the title of "Par\l=e'\sie Analgesique avec Panaris des Extremities Superieures." Since that date he has made numerous communications on the same subject in the same journal, with the reports of eighteen cases. In 1885 M. Broca (Ann. de Dermat. et
more » ... de Syphilog.) published a case, and in 1887 M. Prouff (Gazette Hebdom.), another Breton physician, recorded one, followed by Hanot in the same year. In 1888 d'Oger de Speville collated in a Paris thesis nine cases from various sources. In 1889 Heckel published a clinical observation (Berlin Klin. Wochenschrift). The same year {Sem. Méd.), Gombault reported the autopsy of Prouff s case before the Société Medicale des Hôpitaux de Paris, and in 1890 Charcot {Piog. Méd.) published a clinical lecture on the subject, to which the writer is mainly indebted for the following description and for cuts 1 and 2. A majority of the recorded cases have been among the Breton peasantry, but the condition was first observed in that locality, and possibly is as frequently found elsewhere, though not recog¬ nized under this name or as a disease of the cen¬ tral nervous apparatus. Morvan's attention was first attracted by finding a painless whitlow. In his first paper (1883) he says : Twenty-five or thirty years ago a man of 60 presented himself, with a whitlow on one of his fingers. We made out a necrosed condition of the ungual phalanx and pro¬ posed to make an incision and extract the bone. As the patient gave his permission with reluctance, he was as¬ sured that the incision would be made like a flash, so that he would not have time to suffer. The cut, which was sufficiently free, was accordingly made, but what was our amazement to see the calmness of this man. Not a complaint! Had he been of wood it would have been quite the same. He affirmed that he had not suffered at all. . . . Taking a pin, we thrust it into various portions of the hand and forearm, which were swollen, without causing distress. Originally Morvan stated the three characteris¬ tics of this condition to be, i. Initial pains of a neuralgic sort in the extremities; 2. The appear¬ ance of paresis and analgesia, mainly in the hands; 3. The appearance of successive painless and de¬ structive whitlows. Subsequently he modified this dictum, as cases fell under observation in which sensation was not materially changed, or in which paresis was absent, so that the only characteristic to be insisted upon is destructive and numerous whitlows. The disease has numbered more men than wo¬ men, but the few cases recorded do not justify generalization in this and many other particulars. Instances have been noted at all periods of life from twelve to sixty years, and for the most part occur in individuals exposed by out-door avocations. As it is the lower portion of the cervical enlarge¬ ment that is primarily and mainly affected, the exposure of the neck by these people to the in¬ clemencies of the seasons may be worth noting, en passant, as a predisposing factor. The tangible clinical points of any one case are rather meagre, and, owing to the essentially chron¬ ic and progressive course of the malady, the early phases are often left in doubt through the forgetfulness of the patient. Frequently there is a his¬ tory of neuralgic pains of long duration in the extremities afterwards affected, and this is follow¬ ed by weakness. Sooner or later a felon makes its appearance and, depending upon the condition present as to analgesia, is painful or absolutely free from discomfort, though the swelling, red¬ ness and ulcération may attain a destructive grade. Indeed, the tendency of these inflamma¬ tory disturbances is to produce more than an or¬ dinary amount of destruction and mutilation. There is usually exfoliation of a part or the whole of the terminal phalangeal bone, and the upper ranks are not infrequently lost. The nail matrix is also affected, resulting in dwarfed, claw-like nails, or only slight horny protuberances may be left. When the analgesia is pronounced, an ap¬ parently exquisitely tender felon may give no pain upon manipulation and, as we have seen, not even resent the knife. In this condition the patients have frequently themselves picked out the bony fragments, the slight discomfort not leading them to seek surgical aid. Such fingers present a characteristic appearance. They are short and thick, and if the middle phalanx, or more emphatically if all the phalanges are lost, the presence of the stunted nail at the end of the stump is sufficiently noticeable. It appears as if the finger had been telescoped. (Cuts 1 and 4.) In some cases other evidences of dystrophy are present. The flexures of the fingers and the pal¬ mar folds are liable to cracks and fissures which are difficult to heal, and may present thickened epidermic margins about an indolent ulcerated centre, comparable to perforating ulcers of the
doi:10.1001/jama.1891.02410620006002 fatcat:gycz4e6fsvfjlj7wwakkuwpxhe