spreads. Bullæ are sometimes present but differing from those of pemphigus by the deep inflammatory areola. Croker also reports hemorrhagic vesicles and large bullæ in grave cases, and cites a case of a girl of two years in which the eruption was at first distinctly bullous.

When vesicles become pustules, crusts are often formed which are quite adherent and on removing them a loss of tissue is seen. The ulcers usually have sharp but not undermined edges, often presenting a punched-out appearance. Sometimes there may be only small discrete areas of inflammation ending in necrosis. Severe losses are usually produced by a species of coalescence of smaller ulcers. The wider the slough the deeper the ulcer. When the crusts or

sloughs have disappeared, reddish or purplish marks or pigmentary stains indicate for a time the seat of the previous lesion.

Location of lesion.-From the cases studied it appears that the lesion is mostly localized upon the lower parts of the abdomen, upper parts of buttocks and less often upon the face and scalp. The hands and feet in the acute form of gangrene are generally left free.

30

Pathology-As to the pathology, there is no doubt but that the lesions supervening upon varicella and other pustular eruptions in children are due to microbic invasion under certain constitutional conditions of which the febrile state, tuberculosis and probably congenital syphilis are the chief, but evidently cachexia is not essential. It might be interesting to note in this connection, since the subject of tuberculosis has been considered so thoroughly in the recent discussions of this society, that some of the writers claim that all these cases of gangrene are in tubercular subjects only. But others have noted cases which have come to autopsy where there was no tubercular lesion to be found. In the spontaneous forms we might think that microbic embolism would cause the lesion. This is the case in infectious purpura. The sudden paralysis of the arterioles commanding the vascular cones of the skin produces an intense congestive oedema of the region; the exudate compresses the capillaries, and, if it persists, the absolute localized anæmia produces the superficial necrosis.

Hyde thinks that the process is one which originally depended upon the toxic effects of specific cocci and evidently requires a special soil for its effective operation. Ehlers, of Copenhagen, has discovered the bacillus pyocyaneus (the "Baccillus des grün-blauen Eiters) in two cases of the secondary form. In a case of pemphigus diptheriticus with gangrene Oettinger found the same bacillus. But Neuman found it also in certain internal and cutaneous hemorrhages, while Lartigau31 and others have found the same bacillus in other conditions. Greike32 found in the primary lesions a micrococci in chains which innoculated in the mouse produced a septicæmia. Demme attributed infectious gangrene to a bacillus which he found, not in the blood, but in the nodes of érythema, the vesicles, and in the gangrenous scabs, which innoculated in the guinea pig produced bullæ which became gangrenous and in these lesions the same bacillus was found. It will be seen that the pathology is still sub judice. In my own case I believe the lesions were due to a paralysis of the arterioles, as outlined above, and this was the primary manifestation of a toxic-neuritis caused by the presence or the elimination of some chemical product of the growth of some organism in all probability the tubercle bacilli - which showed itself later in the tempory paralysis.

Symptoms. There is no special train of symptoms. Besides the local conditions there may be severe constitutional disturbances. There is often high fever but this is not always in proportion to the area involved. When the gangrene appears, the fever usually disappears. Vomiting and diarrhoea. are sometimes present and invariably albumen is found in the urine.

Prognosis. The prognosis varies. In most severe cases, especially where long complications intervene, it is unfavorable. The so-called pemphigus gangraenosus usually results fatally-34 in ten or fourteen days. Nearly all the cases reported by Rotch35 which occurred after varicella ended fatally.

Where the gangrenous areas are small and shallow repair commonly occurs, especially in the healthy children and those somewhat advanced in age.

Treatment.

The treatment of these cases is simple. The

general system needs support and quinine and arsenic are without doubt the best remedies. Local antisepsis by the aid of boracic acid solutions and other antiseptics, such as aristol, iodol or iodoform will be sufficient. The sloughs should be removed. Camescarse36 recommends an ointment containing salicylic acid, oil of turpentine, et cetera, for the pain of the spontaneous form.

BIBLIOGRAPHY

1. Traite des Mal. de L' Enfant. Grancher, Comby etc. Tome V. L. 407.

2. Bull. de la Soc. Anat. de Paris. Centralb. f. Chìr. 1896. N. 32.

3. Archives Med. des Enfants, Tome 1. L. 434.

4. Münchener Med. Wochens. 1897, No. 20.

5. Moullin, Treat on Surg. 1895.

6. Baumel, Traite d' Mal. de L'Enf. Tome V. L. 404.

7. Holt, Dis. of Children. 1897, p. 872.

8. Croker, Dis. of the Skin. 1893, p. 219.

9. Am Text Book Dis. Children. p. 1064.

10. Breslaut. Artzl. Zeit., 1879.

11. Deutsche Med. Woch. 1880 and 1884.

12. Dublin Jour. Med. Sc. June, 1880.

13. Roy. Med. Chir. Trans. Vol. LXX, p. 397.

14. Dis. of the Skin. 1896, p. 136.

15. Dis. of the Skin. 1897, p. 198.

16. Bulletin Med. 1889.

17. Thèse de Paris, 1896. Also Revue. Mens. des Mal. d. L'Enfance. Jan. and March, 1897.

18. Archives of Pediatrics, pp. 680 and 684.

19. Deutsche Med. Woch. 1880, Aug. 21.

20. Centralb. f. Kinderheilk. Jahr. III, S. 91.

21. Id. S. 207.

22. Id. S. 274.

23. Shoemaker, Dis. of the Skin. 1897.

24. Sys. Gen. Urinary Dis. Vol. III, p. 373.

25. Phil. Med. Times, 1881. p. 412.

26. Viertelj. f. Derm. u. Syph. J. XII, S. 117.

27. N. Y. Med. Jour. Vol. LXVII, p. 407.

28. Am. Jour. Med. Sc. June, 1884.

29. Jour. Cut. and Gen. Úrin. Dis. Vol. XV, p. 351

30. Brunner, Centralb. f. Kinderheilk. J. I, p. 14.

31. Philadelphia Med. Jour. Sept. 17, 1898.

38. In Thèse de Charmoy.

33. Fortsch der. Med. 1897.

34. Keating, Encyclop. Dis. Child. Vol. II, p. 44.

35. Rotch, Pediatrics, 1896, p. 526.

36. Presse Medicale. Dec. 11, 1897.

TUBERCULOSIS IN CHILDREN.*

BY WILLIAM H. HAPPEL, M. D.,

Instructor in Therapeutics, Albany Medical College; Obstetric Surgeon, Albany Hospital.

It is the purpose of this paper to deal in a brief manner with the clinical aspect of tuberculosis in children.

The disease presents some peculiarities in its course and its modes of attack when compared with the form occurring

*Read before the Albany County Medical Society, March 8, 1899.

in adults. It is much more rapid in its development and frequently much more obscure in its symptomatology.

The tuberculosis of children naturally divides itself into a general tuberculosis, and a tuberculosis of special organs.

No age is exempt from the disease. The belief that it is rare in infancy is no longer tenable. In fact, it is shown that it is much more frequently present at this age than at any other.1 Even congenital tuberculosis is no longer to be doubted although of very rare occurrence.2

In speaking of the tuberculosis of children, we will restrict ourselves to the disease as it occurs in children not older than eight years. After that age, the disease does not differ materially from the form occurring in adults." The predisposing facts may be found in tubercular parents, or in those who have transmitted a weakened condition to their offspring by having become infected with syphilis, or weakened by alcoholism.

The city reared child, from its frequently unsanitary surroundings and its great exposure to infection is exceptionally prone to contract the disease, which may also follow in the train of any acute infectious disease. Local disease of the respiratory tract, such as bronchitis, pneumonia, chronic catarrhs and large tonsils and adenoids are also frequently of ætiological importance.

Not unusually, tuberculosis follows measles, whooping cough and influenza.

toms.

The acute general miliary tuberculosis of children frequently follows some local tubercular process. At other times, it develops rapidly and with extremely severe sympProdromal phenomena are of short duration and very vague. They consist of an irregular but not a specially high temperature, thirst, slight cough, if any, and a rather remarkable dyspnoea when the lack of lung symptoms is considered. These symptoms are quickly followed by high temperature, 103° to 105°, interrupted by as marked falls in temperature, 97%1⁄2° to 97°. The patient wastes very rapidly, becomes cyanotic, restless and delirious, or on the other hand, apathetic and somnolent, without the occurrence of involvement of the meninges. The respirations are markedly frequent. Careful examination may reveal some enlarged lymphatic