DERMATITIS GANGRAENOSA INFANTUM¹

Synonyms.—Varicella gangrænosa (Hutchinson); Pemphigus gangrænosus; Mul­
tiple cachectic gangrene; Infantile gangrenous ecthyma; Multiple disseminated gan­
grene of the skin in infants; Rupia escharotica; Fr., Ecthyma térébrant; Ecthyma
infantile gangréneux; Ger., Ecthyma gangrænosum.

Definition.—Dermatitis gangrænosa infantum may be defined
as a gangrenous eruption observed in children and infants, arising spon-

¹ Literature: Hutchinson, “On Gangrenous Eruptions in Connection with Vaccina­
tion and Chicken-pox,” London Med.-Chirurg. Soc'y Trans., 1882, p. 1, with plate
(this writer also refers to it briefly in Rare Diseases of the Skin, p. 235); Stokes, “A
Case of Vaccinia Gangrænosa,” Dublin Jour. Med. Sci., June, 1880; Howard, “ A Case
of Gangrenous Varicella,” Brit. Med. Jour., May 12, 1883, P. 904; Atkinson, Amer.

428                                      INFLAMMA TIONS

taneously or following other vesicular or pustular eruptions, more
especially varicella and vaccinia.

Symptoms.—A large number of the cases of this rare disease, first
clearly described by Hutchinson, and later by Crocker and others, have
followed varicella. The vesicles, instead of drying up and disappearing
in the usual manner, become crusted centrally, often with a pustular
border, and surrounded with an inflammatory areola. Ulceration begins
beneath the crust and may also take place peripherally, resulting in a
grayish or grayish-black eschar. Closely contiguous lesions may become
confluent and form an irregular ulcer of some size and depth. After a
variable time these eschars begin to separate, showing shallow or deep-
seated ulcers, finally drop off, and leave behind a rounded or oval shallow
pea- to dime-sized or larger superficial scar. As is to be expected, these
escharotic lesions are most numerous in those regions upon which the
varicellar eruption is most abundant. The disease has also been known
to follow vaccinia, in which instances it takes its starting-point in the
neighborhood of the vaccine pustule. Cases which arise spontaneously,
without preceding exanthem, usually are seen first about the buttocks,
and commonly appear as small papulopustules. The malady varies
considerably in severity and gravity. In some the lesions are almost
bullous, sometimes, especially in the grave cases, hemorrhagic In others
the eruption is comparatively mild and scanty. New lesions may appear
from day to day for a few weeks or longer.

The constitutional symptoms, as a rule, bear relation to the cuta­
neous features. There may be high fever, vomiting, diarrhea, cardiac
and pulmonary complications, and even septicemia. On the other hand,
in mild examples, the systemic disturbance is not marked.

Etiology and Pathology—The disease is rare, and is seen usu­
ally in debilitated and anemic infants and young children. It is observed
in those under the age of three, most commonly in the first year, and
more frequently in females. Tuberculosis and syphilis have both been
alleged as possible causes, but an examination of the literature of the
subject and my own scant observations would give but little credence
to these factors. While it probably follows varicella in most instances,
yet a number of cases have been observed which arose independently.
It is doubtless due to some micro-organism, although there has been as
yet no uniformity in the findings; Baudouin and Wickham found in a
case examined by them the streptococcus pyogenes, but were not con­
vinced of its pathogenetic importance. The bacillus pyocyaneus has
considerable support (Ehlers, Hitschmann, Kreibich, and others); and

Jour. Med. Sci., Jan., 1884; Crocker, “Multiple Gangrene of the Skin in Infants and
Its Causes,” London Med.-Ckirurg. Soc'y Trans., 1887, p. 397 (full account of his
own cases and a review of others); Baudouin et Wickham, “Ecthyma térébrant des
enfants,” Annales, Dec, 1888 (with bacteriologic examination); Elliot, “Dermatitis
Gangrænosa Infantum,” Med. Record, May 16, 1891, p. 862; Ehlers, “Deux cas d‘ec-
thyma térébrant des Enfants,” Annales, 1891, p. 793; Hitschmann, Fritz, and Kreibich,
“ Pathogenese des Bacillus pyocyaneus und zur Aetiologie des Ecthyma Gangrænosum,”
Wien. klin. Wochenschr., 1897, No. 50, and “Ein weiterer Beitrag zur Aetiologie des
Ecthyma Gangrænosum,” Archiv, 1899, vol. 1, p. 81; Marshall (1 case), Pediatrics,
Feb., 1898; Lipes, “Dermatitis Gangrænosa Infantum,” Albany Med. Annals, Jan.,
1900, p. 1.

MULTIPLE GANGRENE OF THE SKIN IN ADULTS 429

doubtless in some of the reported cases the bacillus diphtheriæ may have
been the pathogenic organism.¹ Some of these cases are classified by
some writers under ecthyma.

Diagnosis and Prognosis—The appearance of small vesico-
pustular or pustular lesions leading to crusting and tissue destruction
in infants and young children leaves but little chance for an error in
diagnosis. Syphilis should be excluded.

In very young infants, and especially those in which the lesions are
numerous, with considerable destruction, the outlook is unfavorable.
The advent of general septic symptoms, too, must be regarded as of
serious import. On the other hand, many cases recover, even some of
apparently very serious nature.

Treatment.—The constitutional treatment is to be tonic and
stimulating, with abundant proper nourishment. The various remedies
to be advised will depend upon circumstances; in short, the treatment is
symptomatic and expectant. Sodium salicylate, opium, and zinc sul-
phocarbolate have each been commended.

As the disease is doubtless infective, the local management is to be
of an antiseptic character. A 5 to 10 per cent, ichthyol ointment or
lotion, a saturated solution of boric acid with 2 or 3 grains (0.13-0.2)
of resorcin to the ounce (32.), washings with corrosive sublimate solution,
about 1: 2000, are all satisfactory. Aristol or boric acid powder, with
10 to 20 grains (0.65-1.33) of acetanilid to the ounce (32.), may be used
to dust over the ulcerations.

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