MULTIPLE GANGRENE OF THE SKIN IN ADULTS

This term is employed to include several similar manifestations of
cutaneous gangrene, not dependent upon an underlying diabetes, which
have been variously described under the name of spontaneous gangrene
of the skin, disseminated gangrene, hysteric gangrene, gangrenous
zoster, and dermatitis gangrænosa.²

Doubtless some of the instances of gangrene in hysteric girls and
women are of artificial origin,³ but, as Van Harlingen⁴ and others have

¹ Diphtheria of the skin, as usually understood, is a term employed to describe those
instances in which a diphtheritic membrane has formed upon existing cutaneous wounds
or sores, in some becoming extensive and fatal. But it is quite probable that some cases
of gangrenous ecthyma, and of impetiginous and bullous eruptions, as well as some types
of whitlow and similar affections, might likewise be so regarded; cases are on record of
such, in which the Löffler bacillus, usually with the staphylococcus or streptococcus, has
been found in the lesions. Several papers of recent date treating on the subject are:
Labbé and Demarque, Rev. Mens. des Mal. de l'Enfance, Feb., 1905, p. 49 (Impetigo
and Ecthyma); Slater, Lancet, Jan. 4, 1908,p. 15; Bolton, Lancet, April, 1905; Eddowes,
Lancet, Feb. 1, 1908, p. 284 (Ecthyma); Schucht, Archiv, Neisser‘s Festschaft, 1907,
p. 105; abstracts in Brit. Jour. Derm., 1908, p. 239; Dawson, “Cutaneous Diphtheria,”
Brit. Med. Jour., Sept. 24, 1910.

² Rona, Archiv, 1905, vol. lxxv, p. 25, has recorded 5 cases in hysteric individuals,
similar to the herpes zoster gangrænosus hystericus of Kaposi, and in all of which he
believed the lesions were self-inflicted.

³ Riecke (4 cases of artificial origin), Wien. klin. Wochenschr., 1899, No. 14.

⁴ Van Harlingen, “The Hysterical Neuroses of the Skin,” Amer. Jour. Med. Sci.,
July, 1897 (a most admirable paper, with a comprehensive review of the subject and a
wealth of references, to which the reader is referred for the literature of the disease);
Balzer and Michaux (in hysteric girl), Annales, 1898, p. 53; Corlett (girl of fifteen,
apparently free from hysteric tendencies), Jour. Cutan. Dis., 1897, p. 551; Wende (2

430

INFLAMMATIONS

more recently intimated, this can by no means be said of all, and probably
of only a small proportion. Audry¹ makes the suggestion that in some
of these cases it may be due to the iodids or bromids administered.
The lesions may be few or numerous, usually the former, and, as a rule,
begin with an erythematous spot (erythema gangrænosum) which soon
becomes gangrenous, without any intermediate stage, or there may be
slight vesiculation or serous exudation under the epiderm.

In other instances of multiple gangrene the first appearance of the
lesions is somewhat urticarial. While the areas are usually few in num­
ber at one time, new spots continue to arise, and in this manner the proc­
ess may persist for some time. Some lesions tend to spread peripherally.
As a rule, in the large majority of cases at least, there are no grave con­
stitutional symptoms, and in some the constitutional involvement seems
almost or wholly wanting.

Multiple gangrene is commonly seen in girls and women, but it is
also observed in children;² cases in men are rare, but have been reported.
The disease has, in a large number of instances, been noted to follow
accidents, more especially a burn. It has also been noted to follow
systemic disease, such as typhoid fever,³ scarlet fever, measles, malaria,⁴
etc. In a few instances it appeared to be closely similar or identical
with dermatitis gangrænosa infantum.

The causes are doubtless varied, but a fair presumption is that two
factors are necessary; a weakened resisting power in the skin, due to a
general neurosis or a trophoneurotic disturbance or blood-vessel changes,⁵
and a local infective agent. A bacillus has been found by Rooter,
Waelsch, and Hartzell. In Hartzell‘s⁶ case it was present in

cases, girls, aged seventeen and eighteen, of hysterotraumatic origin), ibid., 1900, p. 548
(with pertinent literature references—; Towle ("Gangræna cutis hysterica,” Jour.
Cutan. Dis., 1907, p. 477, with 5 illustrations), from a study of his 4 cases, and an analy­
sis of 90 cases, believes they are almost all self ­produced—some probably unconsciously
during a “somnambulistic state,” from an autosuggestion of a previous wound. This
is also practically the view held by Pernet, “The Psychologic Aspect of Dermatitis
Factitia,” Jour. Cutan. Dis., 1909, p. 547 (with references).

¹ Audry (disseminated—­due to iodid), Jour. mal. cutan., Feb., 1898.

²Zuppinger, “Ueber Spontangangrän im Kindesalter,” Wien. klin. Wochenschr.,
1899, No. 13 (child five years old, extensive, following pneumonia; the writer gives a
recapitulation of cases of spontaneous gangrene in children; usually follows typhoid,
typhus, influenza, measles, tuberculosis, etc; many having the character of Raynaud‘s
disease).

³ Stahl, “Gangrenous Dermatitis Complicating Typhoid Fever,” Amer. Jour.Med.
Sci., 1900, vol. cxix, p. 251 (in returning soldiers; 10 cases out of 144 patients).

⁴ Osier (following malaria, simulating Raynaud‘s disease), Johns Hopkins Hosp.
Bull., Feb., 1900.

⁵ Homer and Heyd, “ Thrombo-angiitis Obliterans: A Clinical and Pathological
Study,” Jour. Trop. Med. and Hyg., Jan. 12, 1912, refers to Buerger‘s theory, and
indicative name given by him—“ Thrombo-angiitis Obliterans” as explanatory of the
cases of pre-senile, or so-called juvenile gangrene, due to the primary formation of
obliterating thrombi in the arteries and veins, and which, according to Homer and Heyd,
may occur in vessels devoid of endarteritis. They were unable to determine, however,
whether the thrombosis is the primary change or whether the condition is a combined
arteriosclerosis and thrombosis, or a condition primarily due to neuritis.

⁶Hartzell, “Infectious Multiple Gangrene of the Skin,” Amer. Jour. Med. Sci.,
July, 1898 (with some references). G. W. Wende and Bentz, “Infectious Dermatitis
Gangrænosa” (fatal case), Jour. Cutan. Dis., 1906, p. 445, found streptococci, staphylo-
cocci, diplococci, and bacilli in the bullæ and gangrenous lesions of the skin during life,
and in the internal organs at the autopsy.

DIABETIC GANGRENE

431

numbers; in the early stage of a patch-formation it was quite super­
ficially seated.

Prognosis and Treatment.—Recovery takes place sooner or
later, although the malady may be persistent and long continued; in chil­
dren the outlook is more grave.¹ Constitutional treatment is essentially
based upon what may appear to be the underlying cause. If neurotic
in character, appropriate treatment should be instituted. In those
cases lacking any demonstrable cause such remedies as arsenic, iron,
cod-liver oil, and the like are most frequently to be employed. Local
treatment is purely antiseptic and sometimes surgical. In Hartzell's
case it was found that thoroughly removing the gangrenous tissue,
especially about the edges, and enveloping with antiseptic applications,
would prevent its further extension.

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