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ulcerative lesions do not start from the vaccine vesicles although they most always begin on the vaccinated arm. But this condition less often occurs now since the more careful application, better virus and subsequent antiseptic measures remove the chances for infection.

Reports of cases following measles are common after a severe epidemic and numerous citations might be given. Of late Lookwod18, Siver and others have reported cases after severe varicella. A peculiar case was desribed by Eichhoff19 which was observed at the Breslau clinic in which after an extensive eczema had been cured, dark red patches appeared on the patient's back, on which vesicles appeared and later ulcers which soon became gangrenous. One case is cited as originating after lichen planus infantum and another upon miliaria rubra pustules.

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The primary or the so-called spontaneous form is that which has resulted from internal or pathological conditions. Cases are on record which have followed tuberculosis, rickets and syphilis and particularly where there is a predisposition to the first. In scarlet fever20, diphtheria21 and in erysipelas," gangrene sometimes occurs spontaneously. It has been known to follow various cerebral and spinal diseases and other neurotic conditions-as already mentioned, also diabetes and cachexia23.

The primary form occurs usually in wretched, poorly nourished children. Morrow24 reports several cases where there has been no preceding varicella, vaccinia or other eruptive disease, but the little patients were anæmic and debilitated with intestinal disturbances and diarrhoea, while the lesions were limited to surfaces which had been covered by soiled napkins.

Under the title multiple cutaneous gangrene in children due to cachexia three cases were reported in the Philadelphia Medical Times 25.

But Hilbert26 records two cases of spontaneous gangrene of the eyelids in female infants under one year old, both children being healthy and well nourished. Somewhat similar cases were reported by Randall recently. recently. Three children of healthy parentage and good environment had an attack of sloughing of the skin of the upper lids and the root of the

nose. The youngest-one year of age-died.

In the other two cicatrization took place and in one the loss of the corneæ was noted. This case was peculiar, since two of the children were at the sea shore and had not been near the third child for some weeks.

Atkinson's case28 did not follow any previous lesion. The ulcers were chiefly on the extremities-the soft parts of one finger being completely destroyed and later extensive ulcerations resulting in gangrene occurred about the face. An interesting case of spontaneous gangrene in a girl of fifteen is cited in a late journal 29 but the previous history of the patient would lead one to believe that the lesion was a feigned condition.

In this category of the spontaneous form our own an excellent example.

case is

It was during July, 1897, that this case presented at the St. Margaret's Home, during the service of Dr. Henry Hun, of this city, to whom I am indebted for the pleasure of studying and reporting it. The following data were obtained:

Bertha G., two years and three months of age at the time of the development of this condition, entered St. Margaret's Home, March 12th, 1897, in apparently good health. She had had none of the diseases of infancy. On entrance there was found a small lesion on the end of the thumb which healed very tardily, leaving for some time a faint pigmentary stain; while on the tip of the little finger of the same hand appeared a similar lesion which affected the matrix and partially destroyed the nail, leaving a slight cicatrix.

The child was well proportioned, but had not shown any mental development. She did not begin to walk until after her admission and for a time, during the course of the lesion, this function was interrupted.

There is a decided tubercular family history. The father died of acute pulmonary tuberculosis, while the mother, 29 years of age, is now in a well advanced stage of this disease. A brother of the patient has been an inmate of the child's hospital for the past four years, suffering from a most obstinate hip-joint disease. This tubercular tendency may be traced back several generations.

The child was apparently in good condition on the afternoon

of July 15th, when it had its usual bath. The next morning the nurse in charge noticed that the child was restless, more irritable than usual and somewhat feverish, so that an examination was made at once. The accompanying cut, taken ten days after appearance of the lesion will show the seat and limits of this peculiar malady.

On first examination there appeared to be an immense flattened bulla extending from a point a little below the umbilicus, upward for a distance of 12 to 14 cm., the transverse diameter being somewhat less. This blister had ruptured spontaneously so that it was flattened except at one or two small points near the right lower margin, which had the appearance of isolated bullæ and on being punctured, discharged a sero-purulent substance. The whole lesion appeared like a large blister from a severe burn and the nurse in charge was questioned as to that possibility. The margin of the lesion was an intense red, changing gradually to purple. The dermis became gangrenous and gradually sloughed off beginning at the circumferences, leaving a denuded area from which a profuse exudate appeared. There was a secondary extension downward reaching nearly to the symphysis, but no resulting gangrene and which healed rapidly, leaying a deep purplish pigmentation.

A short time after the development of the abdominal lesion there appeared quite as suddenly several erythematous spots, varying in size from a split-pea to that of a twenty-five cent piece, about the anterior surface of the neck and upper anterior margin of thorax. From the centre of some of these areas appeared bullæ, while they did not develop in the others. The contents of the bullæ were absorbed or removed by puncture and the lesions, which were of a less severe type, healed without gangrene. There also appeared a bulla on the right upper eyelid and one on the scalp near the lambda. In the cut the characteristic appearance of one of these lesions, after drying up, may be seen. There was a dark purplish ring about the central portion of partially devitalized dermis; this discoloration gradually fading disappeared about the fifth week. The erythematous areas in which no bullæ developed disappeared more quickly. The abdominal lesion healed slowly by granulation and by the middle of October

the purplish pigmented cicatrix alone remained. At present there is a large, irregular fan-shaped cicatrix about 9 cm. in diameter.

At no time did the child have any pronounced fever, although unfortunately the temperature was not taken during the onset. She rested well and took her nourishment without difficulty and did not seem to suffer except when the abdomen was dressed.

The urinary analysis gave a trace of albumen but was not otherwise abnormal.

The fourth week after the first appearance of this lesion a condition corresponding to that of post-diphtheritic paralysis was noted. Attention was called to the fact that the child had become indifferent to surroundings and did not show any desire for food. Mental apathy was marked. There was a weakness of the cervical muscles-the child not being able to support its head and later she could not sit up without support. The arms were moved about indifferently while the legs were symmetrically paralysed-there being no motion whatever. The loss of the knee-jerk was noted. No change in the power of accommodation or reaction of the pupil to light was discovered. Sensory symptoms in very young children are seldom, if ever, to be relied upon and in this case even the approach of a stranger or the nurse when the dressings were to be changed, was sufficient to nullify apparent paresthesia. The bladder was not affected.

This tempory paralysis lasted some weeks when it gradually began to disappear, the loss of motion in the legs enduring the longest. Recovery is now perfect.

This case was chiefly interesting on account of the spontaneous development, the great size of the lesion larger than any previously reported so far as I have been able to ascertain and because of the resulting paralysis.

Definition.--Jackson defines the lesion, in the secondary forms, as consisting essentially in the formation of deep or superficial, round or oval ulcerations, beneath a black slough and following upon a varicella or other pustule. Hyde (in primary forms) believes that there forms a vesicular lesion, with rosy areola that speedily bursts, leaving a blackish slough, about which a circle of eliminating inflammation

To Illustrate Dr. Lipes' Article on "Dermatitis Gangrænosa Infantum."

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