Four patients with acute medical illnesses developed peripheral symmetrical gangrene. All were seen in one hospital within a six-month period. There was no evidence of significant proximal arterial occlusion. Hypotension and poor tissue perfusion were present in each case. There was associated sepsis in three. Diffuse intravascular coagulation was documented in one patient and suspected in another. All patients demonstrated some degree of acute renal failure, and myoglobinuria was noted in two. All patients ultimately died. An appreciation of the seriousness of the etiological factors in patients with peripheral symmetrical gangrene will direct therapeutic efforts toward correction of the underlying disorder and avoid unnecessary angiography or surgical intervention.