Cause8.—While Haller attributes them to malformations and not to separation of formed parts, Chaussier, the first to find in the uterus the separated part, attributes them to gangrene, but Watkinson shows that, although the stump wa,s largely cicatrized, the foot, found in the uterus, showed no trace of putrefaction, and appeared to be in a state of perfect preservation, and therefore excluded the idea of gangrene. Montgomery, Levert, Simonart, have shown that these amputations result from constric tions of the extremities, sometimes by the umbilical cord, most often by bands of false membrane, which, looped about the extremities, complethly cut them off; the bands are developed in the interior of the amniotic cav ity. Whether these bands are due, as Montgomery thinks, to an inflam mation of the fcetal membranes, accompanied by an effusion of plastic lymph, or as Simonart, Moreau, and German authors think, to the am niotic bands, the instances have multiplied, and, by those of Zagorski and of Montgomery, we are able to follow the lesion from its beginning, a simple cutaneous depression, up to a complete amputation. These bands, indeed, fixed by both extremities to the internal surface of the membranes, form rings or loops in which any part of the fcetus may be entangled. But authors are not all agreed as to the action of these.bands. Mont gomery thinks that the ligature, in compressing the vessels more and. more, obliterates those of the bones themselves, whose vitality enclg by the obliteration; and these bones, now soft and friable, are entirely separated by the fcetal movements. He has observed that the skin and soft parte are not divided but depressed inwards to the bone, so that when the sec tion is complete, the skin covering the surface of the section, the stump appears cicatrized. Martin Jena does not believe that the simple liga turing is able to act on the bone, unless it is in a cartilaginous state. He thinks it should limit its action to the soft parts, and the cause of these amputations, therefore, must be exterior. This opinion, given already by Simpson, is not absolutely tenable. It is perhaps true in cer tain cases, that of Martin proves it, but besides that the ligature acts frequently on the cartilaginous parts, these ligatures have often produced incomplete sections only including the soft parts; and the morbid influ ences which cause these bands, and in particular, the inflammation, pro duce functional difficulties and organic malformations, incompatible with the life of the foAus, which succumbs often before the sepamtion is com plete. Finally, the instances of Hecker, Fitsch and Watkinson prove that the mother has not received any accident.
Contrary to the opinion of Braun, who thinks that the spontaneous amputations are produced genemlly on the upper extremities, it is in the lower extremities that Crede and Duplay have most often found them, and generally on the left side. The direction of the cord to this side, ex plains to a certain extent this predilection.
Sometimes, and it is the rule, the stump is cicatrized; sometimes there is a wound, generally little extended, at the centre of the stump. In this case, the bone or the bones of the member are prominent on the surface of the wound, as in a circular amputation, in which the stump would be conical.
In the cases where these amputations are due to a veritable malforma tion, the extremity of the stump has one or more appendages. (Figs. 24 and 25). Sometimes fingers more or less complete with phalanges and nails, sometimes simple cutaneous tubercles; and in these cases, Debout has noted extreme sensibility of the deformed members, due to the enor mous development of the nerve trunks, which does not exist in cases of congenital amputations. Simpson, who has observed five or six of these last cases, believes in a tendency in the human species to a reproduction of a missing extremity, and having seen in a case of Withe, the thumb amputated, first by Withe and a second time by Bromfield, grow again, he supposes that, where the amputation is produced in the early part of fcetal life, at a time when the physiological activity is similar to that of an order less elevated, the lost portion is perhaps at least liable to a par tial and rudimentary restoration. It is only in exceptional cases that these bands become a cause of dystocia. The only case known is that of Bleeck, but Fitsch has observed one, in which the amputated part had been expelled fifteen days before the birth of the child, following spon taneous and premature rupture of the membranes. Most frequently the children are still-born. Gay and Martin have each observed a case of spontanous amputation with birth of living children, and which have survived. On the contrary, in cases where the amputations were simply an arrest of development, the children are often born living. We have seen an example of this: the lesion was double; there was a slender stump of the left leg, with complete absence of the foot, and a rudimentary right foot attached to a very atrophied leg; the child is now two years old. As in the cases of Bleeck and Guv, the child presented by the breech.
Beauregard has noted in the negroes and Hindoos, an affection which he calls dactylolysis, and which, always produced in the little toe, at its base, consists in a circular strangulation, which transforms it into a thin pedicle, which breaks off if not cut off. At the same time, the little toe, deviating from its direction, deformed, triple in size, is converted into a compact spheroidal mass, like a little ovoid. Beauregard, who has com pared this to spontaneous amputations, describes three varieties of ectro dactylia: first, complete arrest of development, true abortion; second bra.chydactilia, arrest of phalangeal development; third, spontaneous am putation. We are dealing here, then, with a defect of conformation and not spontaneous amputation.