38 THE HOSPITAL. October 12,- 1907.

AN UNUSUAL CASE OF RAYNAUD'S DISEASE. The Tongue as well as Extremities Affected. The three degrees of Raynaud's disease?local almost the whole of its terminal phalanx is black the necrosis the bone as syncope, local asphyxia, and local gangrene?are and gangrenous, involving as the soft index has lost much well enough known, and cases exhibiting the first well parts. The of tissue over its second and its third and second degrees of the trouble in the fingers and the phalanx, is little more than a de- toes are not uncommon; the third phalanx represented by very fortunately formed nail. The middle finger is semi-ankylosed, which is.a sad is much rarer. stage, condition, very and its terminal phalanx has disappeared except for The is an of with following example it, together a small and deformed nail. The ring finger is gone Raynaud's disease of the tongue at the same time. altogether. The little finger is- twisted and alto- The patient is a woman now aged 44; there is gether deformed. The left hand digits are all nothing notable about her family history, and, atrophic, cyanosed, and painful, and each has lost except for the ordinary ailments of childhood, she almost the whole of its terminal phalanx; at the ends was perfectly well except for occasional neuralgia of the thumb and index finger there is a tiny corru- in various parts of her head, until she was twenty gated nail; the ring finger is the only one that has eight. She then had her first and only confine- retained anything like its normal size, and even here ment, which was rather long and troublesome. there is extreme deformity by acute flexion at the Three months afterwards, when she had become second interphalangeal joint. The feet present more she noticed March that quite strong again, during acute lesions of a very similar nature. the little finger of her right hand became very cold The heart, lungs, abdominal organs, and urine and white, and painful to pressure. are all natural. The patient has a very fair appetite, Dipping the hand into hot water, or keeping it in and the complexion is good. As regards the general a warm glove, cured the local syncope for the time nervous system, the tendon reflexes are all ex- being, but immediately the hand was allowed to get aggerated, though there is no ankle clonus, and at all cold the little finger at once became blanched the plantar reflex is flexor; the pupils react nor- and painful again. Six weeks later this troublesome mally; the sphincters are natural. When reading, finger, instead of merely going blanched, began to the patient often complains of a mist coming before turn livid, and presently purple. The local asphyxia her eyes, so that she has to lay down her book for a colour lasted month, the bluish-purple deepening, twenty minutes or half an hour before she can go until one day a breach of surface occurred, followed on with it, but the optic discs look perfectly healthy, by a discharge of dark and fcetid pus. The pain in and vision otherwise seems natural. the affected finger was intense. The suppuration Sensation seems to be natural, and nowhere is lasted about six months, and then the place healed there any loss of sensibility to heat and cold, or to over, and the digit recovered a pinkish, almost pain, so that syringomyelia cannot be diagnosed. soon after this normal colour. Very precisely There has been no alcoholism, nor is there any similar changes occurred in the ring finger of the evidence of lead poisoning, nor of ergotism; so that same hand, lasting about the same length of time, Raynaud's disease seems clearly to be the diagnosis. and in the same order. The middle occurring finger, As has been said, the trouble has now begun to ahd then the index followed suit. finger, affect her tongue as well as her hands and feet; and As time went the left hand suffered from the on, this makes her much more miserable. Suddenly, affection the order in which the left too, digits without any obvious cause, and apart from any succumbed being: index, middle finger, ring finger, apparent emotional disturbance, she feels her and little the local in- finger. Presently asphyxia, tongue go cold; she says it feels as though she had stead of became and being recurrent, permanent, an ice in her mouth. The phenomenon lasts a the nails became and from irre- corrugated rough quarter of an hour, during which time she moves formation. When the was 39 gular patient years her tongue about, as though chafing it warm again. old the thumbs, which to then had up escaped She feels it tingling, and any strong pressure on it altogether, became involved too. When she was 41 is acutely painful. The end of the attack is ushered two of the fingers suppurated simultaneously. in by violent and intensely painful throbbings, All this time the feet, sensitive to though very which begin at the tip, and appear to be precisely cold, had never been affected local or by syncope similar to those experienced in hands that are re- local a year that is to asphyxia; ago, however, say covering from exposure to extreme cold. The attack at 43 of the toes became swollen and years age, is often preceded by pain arising in the and there were in supra-hyoid painful, cramps the legs; the region, and thence spreading from behind forward in colour in the toes were not changes noticed much into the lingual region. the herself, because she them well by patient kept When the tongue is examined during one of these but on attention directed to them wrapped up ; being crises it is a deep violet colour, and the livid tint were found to suffer from they paroxysmal syncope lasts some time after the actual attack has passed and asphyxia similar to those of the or a precisely off. The lingual seizures occur once twice and on one occasion the little toe of the fingers, right week; have not hitherto led to foot fortunately they any suppurated spontaneously for some days. or of the but one fears ; suppuration gangrene tongue, The nose and ears wTere not affected at all. that this result is liable to follow some day. At the very _ is thin and present patient pigmented, the Treatment for the condition can do little more than thumb is and and right swollen, red, painful, mitigate the patient's sufferings.