August Jerome Lartigau, M. D., | John H. Pryor, M. D., Buffalo, N. Y. H. Judson Lipes, M. D.. Albany, Arthur G. Root, M. D., Albany, N. Y. William Mabon, M. D., burg, N. Y. N. Y. keepsie, N. Y. Ogdens-William O. Stillman, M. D., Albany, Andrew MacFarlane, M. D., Albany, N. Y. Martin Mac Harg, M. D., Albany, W. H. Morse, M. D., Westfield, William J. Wansboro, M. D., Albany, N. J. J. M. Mosher, M. D., Albany, N. Y. Edward Mass. N. Y. Samuel B. Ward, M. D., Albany, Senator Horace White, Syracuse, O. Otis, M. D., Bo, Reynold Webb Wilcox, M. D., LL. Harry S. Pearse, M. D., Albany, N. Y. J. W. Wiltse, M. D., Albany, N. Y. Dr. Walter Zweig, Berlin, Germany. ALBANY MEDICAL ANNALS Original Communications DERMATITIS GANGRÆNOSA INFANTUM.* By H. JUDSON LIPES, M. D., Instructor of Obstetrics, Albany Medical College Gangrene of the skin of children is fortunately not often observed, nor does it occur very frequently even in adult life. There are numerous varieties of cutaneous gangrene, common to all ages, which present no special feature except their rarity. Such lesions are classified by Renault' as follows: I. Gangrene due to chemical agents.-This would include2 lesions produced by caustics, vesicants and certain medicinal agents. The first two are most frequently seen but they usually involve only the superficial layers and are not of special importance. As an example of the last, the effect of the application of carbolic acid in poultices may be cited as a frequent cause of gangrene, not only of the skin but the deeper structures as well. Pèraire2 has noted five cases resulting from the application of a 1 per cent. carbolic acid solution to the extremities of children; in one instance the amputation of a digit became necessary 24 hours after the first application. 2. Gangrene caused by physical agents.-This is fairly common and includes burns, frost bites and compression. Compression necrosis may be either from external causes, such as too tight bandaging or from internal pressure. In either case *Read by title before the Albany County Medical Society, April 18, 1899. the gangrene is due to the occlusion of the subcutaneous vessels. The pressure makes the skin bloodless, thin and transparent, like parchment, and is observed when there is pressure of the bones of joints in contractures, dislocations, projection of fragments of bone or less often from uric acid. concretions. In congenital paraphimosis gangrene of the prepuce is due to the purse-string like band of skin. The ordinary bed sore-the Hypostatische Druckbrand of Unna-is not so frequently seen in children as in the adult, since the panniculus adiposus is more highly developed, but it does occur in poorly nourished children and in chronic debilitating diseases such as Pott's and hip-joint disease, typhoid fever, et cetera. It is not the pressure alone that causes this condition, but the weakened circulation either from heart disease or vessel paralysis, and the consequent localized hypostatic passive hyperæmia. The localized neurotic or acute bed sore differs from the usual lesion only by its quick development and the insignificance of the external injury. Under this same head would come the necrosis of the skin caused by the oedema of cardiac or renal lesions. 3. Gangrene due to vesicular obliterations including arterial embolism, infectious arteritis, and thrombosis, is seldom met with. In the recent congress at Moscow, Munk3 described a case of spontaneous gangrene occurring in a child of three years, who had had a severe attack of measles complicated with a broncho-pneumonia resulting in the loss of several digits of the right hand-undoubtedly due to a toxic infectious arteritis. Brun, of Paris, noted a case following influenza, from the same cause, where the right foot was affected. An interesting case was reported by Wunder1 where the gangrene following measles was supposed to be caused by a thrombosis of the arteria thoracica longa, its occurrence having been favored by the fact that before and during the illness, the child lay most of the time on the right side. 4. In the dyscrasia, e. g., in diabetes, the lesion does not. differ materially from some cases of spontaneous gangrene except that the prognosis is less favorable. But there is a specific diabetic gangrene, in a certain sense, since all accidental grave or even slight wounds, either from bruises, cuts or erosions, especially on the feet or lower part of the thigh, become very easily gangrenous. 5. Gangrene due to intoxication, e. g., from ergotine, need only be mentioned. 6. The last division of cutaneous gangrene, that which is due to nervous affections. We find it in spinal and cerebral lesions and in toxic neuritis. Raynaud's disease is happily rare at all ages and especially so in children. According to some authors it does not occur in children, but it has sometimes been observed by others." On the other hand there is another variety which is relatively frequent and since it is almost entirely limited to children,789 it has been called Dermatitis Gangrænosa Infantum. This particular dermatosis forms the subject of this paper. It is only during late years that this peculiar condition has come into notice and this principally through the publication of papers in the various medical journals, although perhaps under widely differing titles. It is curious to find such an extensive nomenclature for conditions which can readily be classified under one head, but this diversity, as Van Harlingen states, is probably due to the varied clinical aspects—some certain feature appearing to the observer more prominently than others. Some authors believe the lesion is allied with pemphigus on account of the peculiar eruptions characteristic of that disease and have termed it pemphigus gangrænosus. In 1809 a peculiar epidemic appeared in Ireland which was given that nomen, but Hutchinson claims that this was not true pemphigus. Fagge described a case under rupia escharotica and in the Guy's Hospital museum there are specimens of this disease which according to Barlow, is none other than the one under consideration. Some authors, e. g., Pineau classified this lesion under the name of gangrænous infantile ecthyma. But the more recent works have done away with this extensive and overburdened nomenclature. It Professor Simion10 was the first to individualize this lesion under the name of multiple cachectic gangrene of the skin. was later studied by Eichhoff." Both of these writers included in their papers only the gangrene of cachectic children. Hutchinson was the first to include the gangrenous condition seen as a complication in varicella, and later other English writers, principally Stokes of Dublin12, included vaccina gangrænosa and also that following impetigo. Croker13, in an elaborate article on this condition, divided it into four classes: Ist. where there is no antecedent varicella-there being generally only small gangrenous areas; 2nd. from antecedent varicella; 3rd. resulting from vaccination; 4th. localized spontaneous gangrene. 15 Jackson, describes only two forms, Raynaud's disease and Dematitis gangrænosa infantum. Hyde adopted the latter term. and gives us a more simple classification. He divides the lesion into two varieties: Ist. that following varicella, vaccina or any other primary lesion; and 2nd. that developing without any previous lesion of the skin and accompanied by general infection. This etiological and clinical division has been adopted by Hutnell and his pupils. Caillard, in his thesis, accepts Croker's division but unites the lesions under the name of infectious disseminated gangrene. The more recent French writers classify these lesions under disseminated gangrene of the skin and divide it into gangrène disséminée infestieuse and gangrène desséminée postulcereuse and this seems to be the best classification. Let us first consider the secondary form. This is only a local complication of cutaneous ulceration-the nature of which is most variable. This form is seldom seen outside of institutions except in severe epidemics. It is much more common than the spontaneous or primary forms and usually follows varicella, less frequently vaccinia, measles, et cetera. The subjects of this affection, as already stated, are infants or young children from three months to several years of age. Croker reports twenty-three cases, all not exceeding two years; fifteen of this number being girls, while in two cases the sex was not reported. In the number of cases collected fully three-fourths were girls. When the gangrenous condition follows varicella certain peculiarities have been noted by various investigators. If the onset of the gangrene occurs while the varicella lesions are still present it begins upon the head and upper parts of the body; if after most of the varicella lesions have cleared off, it is most apt to appear about the buttocks and abdomen. When it occurred after vaccinia it was observed that the |