A CASE OF RAYNAUD'S DISEASE

E.J. Fairland
1895 The Lancet  
SURGEON TO THE BRISTOL ROYAL INFIRMARY. AT an operation for the removal of a solid pelvic tumour performed on May 5th of this year a condition of the omentum was found which I have endeavoured to show in the accompanying sketch, life-size. On completion of the parietal incision, which was carried above the umbilicus, there protruded coils of vessels which exactly, in colour and size, resembled fat, well-developed earthworms. They were hard, tense, and glistening, and looked so like worms that
more » ... r a moment I was nonplussed, nor could my experienced assistant, Mr. Swain, or Dr. Michell Clarke, under whose care the patient was, suggest what they were. Prolongation of the incision upwards and a more close examination at once showed that they were the vessels of "'I WW / the omentum. Here and there small tags of areolar tissue containing a little fat could be found on the vessels ; but the whole omentum was transformed into a network of large vessels without any fat. A good many of the vessels were closely adherent to the tumour, these were tied in a bunch and divided. The rest of the omentum was left intact. The whole surface of the tumour was very vascular, and could not be hanclled without causing free bleeding. In spite of rapid delivery and the free use of large pressure forceps a great quantity of blood was lost before any tissue was divided. The bladder was embedded in the tumour, and its adhesions were more vascular than I have ever seen. The patient, a lady aged forty, had suffered severe pains for several years during the growth of the tumour, and was very thin. She made an excellent recovery. The exact nature of the growth has not been made out, probably it will turn out to be a myoma with sarcomatous elements. Bristol. A GIRL aged twenty was thrown out of a dog-cart through the wheel coming in contact with a large stone at the comer of a street. I saw her an hour after the accident. She told me she had stretched out her arm to save herself and had fallen with all her weight on her hand. I found the right hand bruised and cut by the stones. The right elbow was very painful and I was for some time puzzled to account for the pain, all the bony prominences being uninjured and in place, the radius rotating freely, and the movements of the elbow joint being perfect, although accompanied by much pain. Pain was also produced by pressure on the head of the radius. I found, however, that when I grasped the lower end of the humerus in one hand and the forearm in the other, the latter being brought to a right angle with the former, a very slight amount of backward pressure produced a backward dislocation of the joint, the olecranon projecting considerably behind the humerus, and that when the pressure was reversed the joint slipped back into its place with the greatest ease. This proceeding I repeated once or twice, the dislocation being produced and reduced without the least difficulty. I placed a small roll of wool in the bend of the joint and secured it with a bandage round the joint and then put the arm in plaster of Paris with the elbow flexed till the bandage became fairly tight. In three weeks I commenced passive movement and obtained in the end a completely satisfactory result. I cannot account for these symptoms except by supposing that the coronoid process had become separated from the ulna by the fall on the outstretched hand. The great rarity of the accident makes the case worth recording. Slough. A MAN aged twenty-five was admitted to the Royal Victoria Hospital, Netley, on Jan. 19th, 1895. He was invalided from Hong-Kong for malarial cachexia. He had served in China for three years, enjoying fairly good health except for frequent attacks of ague, accompanied by coldness and numbness of his extremities. On the voyage home a bluish discolouration of the lobe of the left ear was noticed, and his hands and feet became benumbed and very painful. On admission he was in a very cachetic state ; the hands and feet were in a condition of extreme venous engorgement, cedematous, and of a purplish colour. This cyanosis implicated especially the toes and forepart of the right foot, the index and middle fingers of the left hand. The point of the nose, the lobe of the left ear, the left thumb and left great toe also became cyanosed ; and at times the right ear was similarly affected. The discolouration of the ears and nose was of a recurrent character, frequently disappearing altogether. Anaesthesia existed in the affected parts, and for some distance above them. At first, however, intense pain was felt in the regions above the cyanosed parts. Gradually the cedema subsided, the livid marbling of the surface disappeared, and early in February half of the right foot, the plantar surface of the left great toe, and the index and middle fingers of the left hand became mummified, shrivelled, and black. A line of demarcation formed above the gangrened portion of the right foot, accompanied by a foetid discharge ; but Nature made no effort elsewhere to throw off the diseased parts. Throughout the attack the pulse remained small and feeble ; the temperature ranged between 97° and 101 F. The spleen was enlarged and tender. The other organs were normal. The urine was non-albuminous. On April 13th Surgeon-Colonel W. F. Stevenson removed the right foot (Syme's amputation) and the diseased fingers. The patient made an excellent recovery. Exposure at sea was the direct cause of the attack. Ague is a, recognised factor in its etiology, and the patient's constitutional tendency to a stasis of the peripheral circulation was increased by his cachectic condition, which produced the lowered tissue vitality essential to the disease. Raynaud's three stages of local syncope, local asphyxia, and symmetrical gangrene were well marked; the case was characteristic in its etiology, progress, and result. The treatment was based on the symptoms-opium to relieve pain, and quinine and generous diet to remove the cachexia.
doi:10.1016/s0140-6736(02)06214-1 fatcat:5rbky46ikvba5fevogc27up4bm