Widespread and sudden occlusion of the small arteries of the hands and feet.

This paper analyzes the syndrome of symmetrical digital gangrene that results from various pathologic processes. If a group of such patients is closely studied, it is apparent that among those who have suffered a sudden and widespread occlusion of the small arteries of the hands and feet some may be grouped apart by reason of the single nature of the attack and the good prognosis. Eleven such examples seen by the author are described and their differential diagnosis, causation, and treatment discussed. FOLLOWING Raynaud's' thesis in 1862 many case histories of minor and major limb gangrene have been selectively described as "symmetrical digital gangrene" because of the bilateral nature of the lesions. This term is not entirely satisfactory. It is apparent that the separation of "symmetrical digital gangrene" from other forms of limb gangrene is, in many ways, artificial and that it is a clinical presentation common to many different disease processes (table 1). In addition , in many cases, sudden occlusion of the small peripheral arteries may cause profound ischemia with cyanosis rather than tissue necrosis and the term "symmetrical digital gangrene" cannot be strictly applied to this less severe group. Among patients who have suffered a widespread and sudden occlusion of the small arteries of the hands and feet, with and without gangrene, some may be grouped apart by reason of the good prognosis that the disease carries and the absence of any etiologic factor. In this paper 11 such examples are described of digital gangrene or profound cyanosis of sudden onset occurring in 2 or more limbs; many of these have been reviewed for periods up to 15 years after the acute illness, and something of the natural history of the condition is described. Some of the more severely affected patients resemble those described by Raynaud' under the title of "sym-metrical gangrene of benign form": Lewis and Pickering2 added further case histories of "bilateral gangrene of digits in the young and with infection" and comprehensively reviewed the subject to that date. A history of normal health for years prior to the occlusive episodes was common to all the patients and more especially none had noticed "white fingers" or hemoglobinuria following exposure to cold. Physical examination failed to reveal any evidence of systemic disease although 4 of the patients had an associated pyrexia; Wassermann reactions and tests for autohemagglutination3 were negative. The reactive hyperemia test4' and arte-riography were …