e the parts usually affected. In the most
extreme degree the parts are swollen, stiff, and livid, and the
capillary circulation is almost stagnant; this is local or symmetric
gangrene, the mildest form of which follows asphyxia. Small areas of
necrosis appear on the pads of the fingers and of the toes; also at the
edges of the ears and tip of the nose. Occasional symmetric patches
appear on the limbs and trunk, and in extensive cases terminate in
gangrene. Raynaud suggested that the local syncope was produced by
contraction of the vessels; the asphyxia is probably caused by a
dilatation of the capillaries and venules, with persistence of the
spasm of the arterioles. According to Osler two forms of congestion
occur, which may be seen in adjacent fingers, one of which may be
swollen, intensely red, and extremely hot; the other swollen, cyanotic,
and intensely cold. Sometimes all four extremities are involved, as in
Southey's case, in a girl of two and a half in whom the process began
on the calves, after a slight feverish attack, and then numerous
patches rapidly becoming gangrenous appeared on the backs of the legs,
thighs, buttocks, and upper arms, worse where there was pressure; the
child died thirty-two hours after the onset. The whole phenomenon may
be unilateral, as in Smith's case, quoted by Crocker,--in a girl of
three years in whom the left hand was cold and livid, while on the
right there was lividity, progressing to gangrene of the fingers and of
the thumb up to the first knuckles, where complete separation occurred.

A considerable number of cases of apparently spontaneous gangrene of
the skin have been recorded in medical literature as occurring
generally in hysteric young women. Crocker remarks that they are
generally classified as erythema gangraenosum, and are always to be
regarded with grave suspicion of being self-induced. Ehrl records an
interesting case of this nature with an accompanying illustration. The
patient was a girl of eighteen whose face, left breast, anus, legs, and
feet became affected every autumn since her sixth year, after an attack
of measles. At first the skin became red, then water-blisters formed,
the size of a grain of corn, and in three days reaching the size of a
hazel-nut; these burst and healed, leaving no scars. The menses
appeared at the fifteenth year, lasted eight days, with great loss of
blood, but there was no subsequent menstruation, and no vicarious
hemorrhage. Afterward