Mr. Astley Bloxam has kindly communicated to me the particulars Of a case of spontaneous gangrene which was under his care in the Charing Cross Hospital. The child—a little girl of ten months old—had been ail ing for eight weeks. A small pimple then appeared on the region of the inferior angle of the scapula. The next day a head formed on the pimple, and became filled with purulent fluid. When the child was admitted a day or two afterwards (on August 19th) she was seen to be pale and thin, and was said to be wasting. The whole of the scapular region on the right side was oedematous, red, boggy, and hot. In the centre was a purpuric patch an inch and a half long by three-quarters of an inch broad, the bor ders of which were quite purple. On palpation the patch gave a boggy sensation to the finger, as if from fluid underneath the skin. The tempera ture on the first evening was 101.8°.
On August 20th the patch had slightly enlarged. Temperature : in the morning, 100.6° ; in the evening, 101.2°. Pulse, 96 ; respirations, 60.
On August 21st the patch was much larger, measuring three and three quarter inches long by two and one-half inches broad. Some bullet had appeared on the surface, and one of these had burst, leaving a small slough. There was no tenderness at the gangrenous part ; indeed the opposite appeared to be the case, and the part seemed to be unusually devoid of sen sibility. Temperature : in the morning, 98°; in the evening, 99.6°. Pulse, 120 ; respirations, 60. An ammonia and bark mixture was ordered, and in the evening the part was well painted with strong nitric acid. The applica tion caused no pain. Thirty drops of brandy were ordered every three hours.
After this the slough did not further increase. On the contrary, it be gan to separate, and the surrounding (edema to subside. There was a little diarrhoea. On August 24th part of the slough came away and exposed the muscles. The child became very fretful and weak, and died rather sud denly on August 29th.
When the gangrene attacks the extremities, it may be seen in the fingers and toes, or may spread to the hands and feet, or even higher up in the limb. Children so affected are usually pale, under-nourished, and cachectic in appearance. After a few days of more or less irritability, loss of appetite, headache, sleepiness, and general malaise, the patient begins to complain of severe pains in the toes, which may extend for some distance up the legs. At the same time the ends of the toes are noticed to be dull red or purple, and their sensibility is found to be blunted. The pains continue. There may be some fever at night, and in the morning the lividity of the ends of the toes is seen to have extended to the circumference of the nail. At this point the symptoms may subside, the pains becoming moderate, and the lividity fading and disappearing ; or, on the contrary, the disease may go On to complete sphacelus, and extend to the whole of the foot or even of the limb. Thus, Francois records the case of a child, three years of age,
in whom the gangrene involved the whole of the foot and lower part of the leg.
This form of gangrene may be dry or moist. If the former, it assumes the characters of senile gangrene, becoming separated by a line of demar cation, and subsequently detached. Raynaud reports the case of a little girl, aged eight years, of good constitution and healthy appearance, who began to complain of severe pains in the feet and lower halves of the legs. At the same time the ends of the toes were noticed to be blue. The pains increased and the child was a little feverish. The fourth toe on each foot became slate-coloured, and the other toes showed spots of livid red. The mortified parts were insensible to the touch, but the pains continued and were worse at night. The appetite remained good, and there was no diar rhoea. After a few days the pains ceased, and the gangrenous patches be came limited by a well-defined line. In about a fortnight the toes desqua mated. Dry brown scabs became detached, and left the skin beneath them tinted of a pale violet colour. On the fourth toe of the right foot, the one which had exhibited the largest patch of gangrene, a black crust was thrown off, and a suppurating surface was left which quickly healed.
A very similar case has been published by Dr. Southey. In this the spots of gangrene were accompanied by subcutaneous mottlings of the trunk and limbs. These mottlings developed into a raised rash like ery thema tuberculatum. The eruption at first itched, then became tender and painful, but eventually subsided, leaving merely a discolouration of the skin. Recovery in such cases is sometimes followed by an attack of par oxysmal hannaturia, in which large quantities of crystals of oxalate of lime are passed with the urine.
In the moist gangrene of the extremities the affected part—which is commonly the end of a finger or toe—is swollen, and the epidermis is raised up by red serous effusion. As the destruction of the tissues of the part proceeds, the articulation may be laid open. Sometimes moist gangrene of the extremities is combined with disseminated spots of a kind similar to those previously described. Thus, MAI. Rilliet and Barthez refer to the case of a little girl, aged four years, who was under the care of Legendre. In this child moist gangrene attacked the ungual phalanges of the right thumb and middle finger—in the latter laying open the second articulation —and the ungual phalanx of the left forefinger. Moreover, gangrenous blebs filled with bloody serum formed at the back of the shoulder, in the lower part of the dorsal region, and in other parts of the body. At last a double pneumonia declared itself, and the child died on the ninth day from the beginning of the illness.