A Case of Syphilis in which Several Fin- 
gers of Both Hands Became Cold and 
Livid; Suspected A rteritis. 
BY C"' 
HERMANN G. KLOTZ, M. D., 
Member of the Neiv York Dermatological Society and of the American Dermatological Association 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
August, 1889. Extracted from the 
American Journal of the Medical Sciences for Au»ust, 1889. 
A CASE OF SYPHILIS IN WHICH SEVERAL FINGERS OF 
BOTH HANDS BECAME COLD AND LIVID; 
SUSPECTED ARTERITIS. 
By Hermann G. Klotz, M.D., 
MEMBER OF THE NEW YORK DERMATOLOGICAL SOCIETY AND OF THE AMERICAN 
DERMATOLOGICAL ASSOCIATION. 
The title of this paper has been adopted from one published by Mr. 
Jonathan Hutchinson, of London, in 1884 (Medical Times and Gaz., 
1884, i. p. 347). The close resemblance which my case bears to that of 
Mr. Hutchinson will, I believe, j ustify its adoption. 
John W., twenty-five years of age, born in New York, a butcher by 
trade, applied for treatment at the German Dispensary on February 28, 
1889, and gave the following history: He had a chancre about three 
years ago. As soon as it was healed, he got ulcers on the back, of which 
large scars remain. He took medicine until all the ulcers were healed up, 
but none afterward. In February, 1889, ulcers broke out again on the 
back, penis, nose, and scalp, and are still present, showing unmistakably 
a syphilitic character. Besides, he complains of an affection of several 
fingers of both hands. 
About a month ago he noticed that the tip of the right fifth finger 
was white and somewhat shrivelled in the morning. After three days 
the finger became blue and very painful near the tip. The pain was 
spontaneous-not increased by touch or pressure; it lasted day and 
night, and was so severe as to prevent the patient from sleeping. After 
a few days the pain decreased, the tip of the finger remained blue and 
showed a thickening of the skin under the free border of the nail. The 
fourth finger of the same hand became white soon after the fifth, and 
within a few days, without causing any pain, assumed the same bluish 
color, and, like the fifth, began to feel cold and to look shrivelled, par- 
ticularly in the morning. A few days later the third and fifth of the 
left hand underwent similar changes, and about a week ago the fourth 
finger of the same hand in its turn became affected. In the morning 
the blue color is particularly distinct, the affected fingers are shrivelled, 
feel cold and somewhat numb, as if they had been exposed to severe 
cold; after rubbing them for a while, the sensation of numbness ceases 
almost entirely. 
On examination I found the fourth and fifth fingers of the right hand 
of a decidedly bluish, somewhat mottled appearance, and distinctly colder 
than the other three fingers, which presented a perfectly natural appear- 
ance. On the affected fingers the free border of the nails appears re- 
markably white; next to the free border a zone of fine reddish streaks 
surrounds the nail, which looks dark blue like the entire distal phalanx. 2 
KLOTZ, SYPHILITIC ARTERITIS OF FINGERS. 
This color extends over the whole finger, diminishing in intensity toward 
the knuckles. The fingers are not tender to the touch or to pressure. 
In the centre of the tip, close to the nail, on the fifth finger the epider- 
mis over a well-defined spot, about the size of a silver five-cent piece, is 
thickened, the surface being brittle and slightly scaling. The fourth 
fingei' exhibits nearly the same condition, the thickening of the epidermis 
only being less pronounced. The othei' fingers and the hand itself do 
not show any change of color or temperature. 
A similar condition is observed on the third, fourth, and fifth fingers 
of the left hand, the fourth being somewhat less affected than the two 
others. There is the same livid mottled color, the whiteness of the free 
border of the nails, the zone of bluish-reddish streaks around the fixed 
part of the nails, the blue color being most pronounced at the distal 
phalanx, but extending as far as the knuckles, and there is the same 
coldness. There is no clubbing of the end of either finger. Touching 
or pressing the fingers does not cause any pain. 
On both wrists the pulse can be distinctly felt, the radial as well as 
the ulnar, the latter, naturally, somewhat less distinctly. Neither at the 
fingers, the hands nor arms can a thickened bloodvessel be felt. 
At the next visit of the patient, March 5th, all pain in the fingers had 
disappeared, but otherwise there was no change in their condition, only 
that the thickened epidermis at the tip of the right fifth finger had 
dropped off in the shape of a dry, thick scale, leaving a healthy surface, 
and that a slight thickening of the epidermis of the tip of the left mid- 
dle finger had manifested itself The ulcers on the back and elsewhere 
showed a healthy condition and were beginning to heal. The treatment 
inaugurated on the first visit, the biniodide of mercury with iodide of 
potassium internally, and mercurial plaster locally, was continued. 
The patient again put in appearance on March 19th, having neglected 
to take his medicine regularly, and having indulged in drinking beer 
freely. The former ulcers were almost healed, but some new pustules 
had appeared on the scalp, face, and chest. The affected fingers still 
presented the same conditions; bluish color, some shrivelling of the tips 
and coldness. The thickening of the epidermis of the right fourth and 
third left fingers has fallen off, leaving a slightly depressed but healthy 
surface. 
On April 16th, after several weeks of continued treatment, not only 
were all the ulcers healed except one over the right eyebrow, which 
presented a healthy granulating surface, but the affected fingers had 
resumed their normal appearance and temperature. The patient says 
that in the morning they still feel slightly cold for a while, and that in 
lower temperature they become more easily blue and cold than the 
unaffected ones. 
Several attempts to measure the difference in temperature between the 
affected fingers and healthy portions of the hand with the thermometer 
unfortunately proved futile, owing to the want of precise instruments. 
The usual medical thermometers do not indicate a temperature as low as 
that of the affected fingers, which was certainly a good deal less than 
91° F. After procuring another thermometer with a lower scale, the 
temperature of the normal portions changed so rapidly, as soon as the 
patient entered from the waiting-room, and as soon as the fingers had been 
handled somewhat, that the results of measuring could not be relied 
upon. Later on, the rapid improvement in the condition of the patient KLOTZ, SYPHILITIC ARTERITIS OF FINGERS. 
3 
did not allow of further experiments. So the difference in temperature 
could only be determined by the hand, but it was sufficient to become 
evident to every observer. 
The subject of Mr. Hutchinson's case was a patient, thirty years of 
age, in the fourth year of undoubted syphilitic infection. He presented 
coldness, lividity, and pain of the fingers of the left hand except the 
thumb, which at least was but slightly affected. On the ring-finger at 
its bulb there was a troublesome sore. It consisted of a " subcuticular 
suppuration with livid edges. It is very tender," says Hutchinson, " but 
in all other respects resembles those which I have seen on fingers after 
section of nerve-trunks." There was 10° difference between correspond- 
ing parts of the little, middle, and ring-fingers (near their ends) of the 
two hands; the ends of the left fingers averaging 76°, while those of 
the right hand were 86°. The pulse at the left wrist was nearly as 
strong as that at the right, and there was no evidence of occlusion of 
veins. The ulnar nerve could be easily felt, and was not enlarged on 
the affected side. The patient complained that it caused more easily 
pains and tingling when it was pressed on the affected side, than on the 
other. Under specific treatment after six months the pain had ceased, 
the temperature of the ring-fingers of the two hands was the same; the 
affected fingers were much thinner than those of the other hand. 
"This case," Mr. Hutchinson says, " was under my observation nearly twenty 
years ago. I have abstained from publishing it-although in my experience 
almost unique-because I was quite unable to offer any satisfactory conjecture 
as regards diagnosis. It was only the other day on reading over the notes 
again that it occurred to me that the cause of the symptoms must have been 
inflammatory occlusion of the arteries of the hand. At the time the case was 
under care, this diagnosis never crossed my mind, and consequently I failed 
to investigate certain points, which might have confirmed or refuted it, chief 
amongst these being, of course, the state of the digital vessels and of the 
ulnar artery. But, at the time, my mind was preoccupied by the hypothesis 
of nerve cause, to which the severe pain seemed to point. My notes state 
that the radial pulse was not materially weaker than that of the other wrist, 
but it will be seen that the symptoms were more marked on the ulnar side. 
It is, besides, very possible that the arteritis, if such there were, began periph- 
erally, and travelled upward. Possibly it never reached the larger trunks." 
"It is in part the impossibility," Mr. Hutchinson continues, "of explaining 
the symptoms on any nerve hypothesis, which induces me now to resort to 
that of local arterial occlusion. The fingers affected were not those supplied 
exclusively by any one of the nerve-trunks of the forearm, and there never 
was any loss of sensation or of motor power, nor were the local changes such 
as those which we recognize as common in any form of paralysis. They were 
lividity, coldness, and pain; for the most part indicative rather of disturbance 
of nutrition and occlusion, than of nervous influence. A certain school of 
observers will probably claim the case as an instance of disease of the vaso- 
motor system, but, in reply to that, I must allege that we know nothing of 
the occurrence of such symptoms as were here present, in cases in which the 
ganglia or trunks of the sympathetic have been proved to be involved in 
disease, or destroyed by injury." . 4 
KLOTZ, SYPHILITIC ARTERITIS OF FINGERS. 
At the conclusion of his paper, Mr. Hutchinson further says: 
''Although the finger-tips never actually went into gangrene, they were very 
near it. The disease differs from the cases described by Reynaud, under the 
name of peripheral asphyxia, inasmuch as it did not involve all the digits, 
and was marked by extreme pain. Since its occurrence I have seen several 
cases favoring the belief that arteritis may begin in the small peripheral 
vessels, and may travel to larger trunks. If in this instance it began in the 
vessels of the middle finger, and spread upward and involved the superficial 
palmar arch, the phenomena might be fairly well accounted for. Whether 
in my case syphilis was the cause may be open to some doubt, since the 
patient had been for some months under efficient specific treatment, and was 
just well of all other symptoms." 
I have largely quoted from Mr. Hutchinson's paper because most of 
the deductions made by him from his case may be applied equally well 
to my own. The symptoms are the same: lividity, coldness, and pain, 
although the latter in a minor degree. Arteritis beginning in the small 
peripheral vessels and extending centrally, may well account for them ; 
a narrowing of the vessel without complete occlusion furnishing a suffi- 
cient explanation. Whether or not an artery of so small a calibre as 
he digital artery, affected with arteritis obliterans, must necessarily be 
accessible to the touch, so that it can be felt as a hard, thickened cord, 
seems open to doubt. I, therefore, do not believe that the absence of 
such evidence in Hutchinson's case as well as in mine renders the diag- 
nosis of arteritis inadmissible, while, of course, its presence would scarcely 
leave room for doubt. There need be less hesitation about assuming the 
syphilitic origin of the arteritis, if, indeed, there were any, in my case, 
as other symptoms of the activity of the disease were plainly manifest 
on the patient. 
In a former paper, read before the Section in Dermatology and 
Syphilography, of the Ninth International Congress at Washington in 
1887 {Transact., iv. p. 173, and New York Medical Journal, Oct. 8.1887), 
I maintained the occurrence of gangrene of the skin in consequence of 
arteritis obliterans, due to syphilis, as a cause of ulcers. In citing the 
same paper of Mr. Hutchinson, I stated then that it would require the 
anatomical proof that changes in an artery, leading to a gangrenous 
portion of the skin, must actually be shown to exist, in order to establish 
as an irrefutable fact what I had maintained. Since then an observa- 
tion has been published which furnishes sufficient proof that a subacute, 
specific, and syphilitic arteritis of the small arteries of the fingers does 
exist, travelling from the periphery toward the centre-that is, an ascend- 
ing arteritis-a paper entitled: " Gangrene spontanee des Doigts par 
Arterite syphilitique, par le Dr. Baron d'Ornellas " de Dermatol., 
Jan. 1888, p. 35). 
The patient who forms the subject of the paper was forty-five years of age, and 
had had a chancre twenty years ago, which healed without treatment, and was 
not followed by secondary symptoms. At the time he was examined, however, KLOTZ, SYPHILITIC ARTERITIS OF FINGERS. 
5 
he presented tertiary syphilitic lesions of the tongue. For six weeks the 
four fingers of the left hand had constantly felt cold, when the soft parts of 
the ulnar aspect of the tip of the left middle finger became gangrenous. Along 
the course of the collateral arteries of the diseased finger hard strings could 
be distinctly felt, and the radial pulse was found to be considerably weaker 
than that of the other wrist, although perfectly perceptible. Later on, the 
radial aspect of the fourth finger became gangrenous, accompanied by con- 
siderable pain, particularly at night. Seven weeks after the first attack, which 
had passed off under treatment with iodide of potassium, with loss of the 
pulp of the third and fourth fingers, the same fingers in their entire length 
again became painful and cold, but in a more aggravated manner. The sen- 
sation extended to the lower third of the forearm, and within six days the 
middle finger became mummified as far as the proximal third of the second 
phalanx, and the fourth finger as far as the proximal third of the third 
phalanx. D'Ornellas could establish the entire absence of the arterial pulse 
in the left radial artery, in the palmar arch, the ulnar, and in the inferior 
third of the brachial artery, as well as the fact that these vessels were obliter- 
ated and indurated, giving the sensation of a hard string. In the middle 
third of the brachial artery pulsations were rather weak, but in the axillary 
they were perfectly normal. Under specific treatment the affected fingers 
healed, but with the loss of the gangrenous portions. 
Here we have a clear case of arteritis obliterans in a syphilitic person, 
affecting first the smaller arteries and later on larger branches, and 
causing a similar chain of symptoms as found in Hutchinson's and in 
my case: coldness, pain, and mummifications; lividity is not prominently 
mentioned, but there can hardly be any doubt that it existed at some 
time. It may have seemed less significant owing to the early appearance 
of gangrene, the result of the complete obliteration of the bloodvessels, 
which in the other cases probably never really took place. 
D'Ornellas evidently was not cognizant of Hutchinson's publication, 
for he says that he never heard anybody speak of such localized arteritis 
in the extremities, and that Verneuil, Fournier, Duplay, and other emi- 
nent physicians assured him that they had never seen a similar case, 
concurring at the same time with his diagnosis. G. Thibierge, however, 
in a recently published paper ("Les Lesions arterielles de la Syphilis," 
Gaz. d. Hopit., 1889, No. 11), placing Hutchinson's and d'Ornellas's 
cases together, says : " In other cases lesions, which it seems legitimate to 
attribute to syphilitic arteritis, produce asphyxia and gangrene of the 
extremities, closely resembling the type of Reynaud's disease." 
I trust that this paper will be accepted as a further contribution to 
this chapter of the pathology of syphilis. THE AMERICAN JOURNAL 
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