Sometimes the gangrene penetrates completely through the skin and subcutaneous tissues. It may then be found in two forms : a moist and a dry variety. In the moist form the gangrenous patch is black, softened, and infiltrated with a dirty, reddish fluid. Its odour is excessively offensive, and the tissues affected appear to be completely converted into a putres cent pulp. Often it begins as a small pimple, which changes into a bleb containing thin purulent matter. As the process continues, more and more skin becomes involved, and a considerable extent of surface may be red, oedematous, and boggy to the touch. The centre is usually purple. On this surface blebs form and burst, leaving spots of gangrene. The sloughs unite, and if the 'patient survive may become limited. The gan grenous part is then thrown off, the under muscles exposed.
When the gangrene assumes the dry form its anatomical characters are similar to those of senile gangrene. MAI. Rilliet and Barthez describe a case in which the skin of one leg was completely mortified. On the toes it was shrivelled and blackish. Elsewhere it was transparent, hard, red dish, and elastic like a piece of parchment. The dried skin was so trans parent that the injected venous radicles could be seen ramifying on the under surface, and it had a curious resemblance to the rind of bacon.
In some cases ante-mortem clots have been found in the arteries lead ing to the affected part ; but in not a few cases no embolus is to be found in the femoral or other arteries of the diseased limb.
A common seat for this spontaneous gangrene is the vulva in the fe male child. Here the gangrene usually begins on the labia, and may spread thence to the interior of the vulva, to the anus and. the sacrum. The affected parts are dry and blackish-brown, and may slough off, leaving the muscles exposed. In male infants the scrotum is sometimes attacked. Often the patches of gangrene are not limited to one region or to one limb, but occur in scattered spots of various sizes situated on the legs, the arms, the buttocks, or other parts of the body. The lesions are then often symmetrical, attacking corresponding parts of the surface on the two sides.
Symptoms.—Children the subjects of this tendency to spontaneous mortification are liable to attacks of what has been called "local asphyxia." Some part of the body—usually a finger, a toe, or the whole of a hand, a foot, or even a excessively painful, and is noticed to be purple in colour. It feels cold to the touch. The tint may deepen to a dull leaden hue. After three or four hours, during which the greatest anxiety has been excited, the "Pain subsideS ; the colour of the part grows lighter and then becomes normal, and the natural warmth returns to the skin. These attacks are sometimes accompanied by severe abdominal
pain. Occasionally, too, they are followed by hmaturia, of a distinctly intermittent character, the water being normal at some times, red with blood at others. The attacks of local asphyxia do not always subside harmlessly. In some cases the symptoms grow slowly worse, and the af fected part becomes gancfrenous.
Gangrene occurs in two principal forms : disseminated and more or less symmetrical gangrene, and gangrene limited to the extremities, the vulva, or the scrotum.
In the disseminated variety the disease begins in scattered nodules or patches. The child for some days appears to be unusually drowsy, and then, if old enough to speak, complains of pain in some part of the body— the thighs, legs, buttocks, or arms—and livid patches make their appear ance, which grow rapidly darker in colour. The patches are hard and tough to the touch, and seem to be tender, for pressure elicits signs of suffering. If the patches are few and small, the general health may be little affected ; but if they are large or numerous, there may be vomiting, headache, and general malaise.
Dr. Southey has reported the case of a little girl, two and half years of age, who had a feverish attack accompanied by purpuric spots on the limbs. She soon recovered, but some months afterwards had a second at tack which lasted three days. About a fortnight later the child complained of headache, and said she had hurt her legs. The pain was increased by friction of the limbs. In rubbing them it was noticed that the skin on the backs of the calves was livid. Soon afterwards the child vomited, com plained of headache, and was feverish. Towards the evening the patches were seen to have extended up and down the calves and to be darker in colour. A similar appearance was noticed at the backs of the arms, and on the following morning the buttocks had become livid.
When admitted into the hospital on the second day the child was mori bund. The pulse at the wrist was feeble and somewhat wiry, but could still be counted. The tibial pulse could not be detected. The patches of lividity felt hard and tough. The lungs and heart appeared to be quite healthy. Brandy and milk were given, and two doses of nitro-glycerine, but all were vomited. Intelligence was preserved until evening. Convul sions then occurred, and were frequently repeated until the child's death at 11 P.M. The illness altogether lasted only thirty-two hours. A post mortem examination of the body discovered no coarse lesion of the viscera, nor could any embolus be detected in the femoral or other arteries of the left lower limb, which was the only one examined.