Professor of Skin and Venereal Diseases, Post-Graduate Medical School of Chicago; Fellow of the Chicago Academy of Medicine.

An Austrian, 30 years of age, single, first appeared in my clinic at the Post-Graduate Hospital in August, 1893. From the spinal column, right side, between the seventh and twelfth ribs, and in a line extending downward and forward toward the sternum, there was scattered an irregular eruption corresponding anatomically to the course of the underlying intercostal nerves and their cutaneous branches. Between the several groups of this eruption were hypertrophic scars, evidently from a previous attack. The more recent group of eruptions presented, upon a hyperæmic, slightly oedematous base, a vesicular appearance. The older were marked by depressed centres exuding a considerable quantity of pus, and were covered with detritus. The slough was brownish-black in appearance. Here and there some of these defects extended through the Malpighian layer and the corium to the subcutaneous cellular tissue. Some of them were almost onehalf inch in length by about one-quarter to three-eighths of an inch in breadth.

The patient gave the following history: About two years previous to his present attack, or in August, 1891, he was suddenly seized with marked pain in the right side, which was more severe on respiration. This was followed within a few days by a peculiar reddening of the skin. Over this reddened area appeared groups of vesicles, those situated upon the back disappearing in about two weeks, while those

forward and situated about the edges of the ribs became oedematous, painful, and ulcerated. The patient attributed this condition to the medicament employed. The treatment was changed, but the condition persisted for about four months, during which time there was extensive destruction of the integument surrounding the primary lesions. These disappeared, leaving hypertrophic scars devoid of pigment. During his treatment at the Post-Graduate Hospital the large necrotic areas disappeared, leaving scars of a like character.

The patient reappeared at the hospital in September, 1894. This time he had a marked vesicular eruption of the type usually observed in herpes zoster, extending somewhat upward, and another group somewhat below the seat of the previous attacks. Around each individual vesicle was considerable infiltration. Through the larger vesicles could be seen a darkened change taking place near the centre of the vesicle, in the Malpighian layer of the skin. This was undoubtedly the first of the necrotic changes which subsequently followed. In the course of a few weeks, or about the middle of October, some of these had disappeared; the larger number, however, became more prominent, more raised, the epidermis covering the vesicles rupturing, leaving a large number of open necrotic ulcerations, many of them coalescing, with large, irregular loss of substance. The pus showed no apparent evidences of specific infection.

The patient has been constantly under treatment. He is a neurotic of a decided degenerative type, has hysterical attacks, suffers from frequent fits of depression, and has constantly recurring digestive disturbances. During this time he has also had an herpetic eruption, and a herpes zoster frontalis, which disappeared in the course of two weeks, leaving no apparent changes in the skin. He has also had an herpetic eruption in the neighborhood of the sacrum and coccyx, followed by disturbances of micturition which have since persisted, although the eruption has disappeared leaving no apparent changes in the derma.

The affected area does not react even under a strong faradic current; whereas the reaction is more than normal with the galvanic current. There is diminished sensation over most of the right side.

Doutrelepont, under the title "Hysterical Spontaneous Gangrene of the Skin," describes the case of a young girl in whom, following a wound with a pin, there appeared a vesicular eruption upon the left cheek, followed successively by large gangrenous patches and keloidlike scars. In June, 1889, Doutrelepont called attention to the fact that the patient had had recurrent attacks. There were also marked symptoms of hysteria.

*Congress Deutsche Dermatologische Gesellschaft, 1886.

The

Kaposi,* under the name of "zoster gangrenosus recidivus," reported a case in which there had been thirteen recurrences. first appearance was in the region of the brachial plexus on the right side; afterwards a zoster sacro-cruralis; later a zoster cervico-brachialis. Under the title "Atypischen Zoster Gangrenosus und Zoster Hystericus," Kaposit describes four cases, three of them women:

Case 1.-A woman, single, age 27, seen in February, 1889. Over the right breast there were blackish-brown to brownish-yellow ulcerations involving the upper dermal layer, sharply defined, eight centimeters long by one and a half wide, amid irregular and sharply defined discolorations of the skin. The skin was swollen around these places, and rose-red in color; there were a number of keloid-like scars. The eruption had existed about eight days. There had been a similar attack in 1888, lasting three weeks, and leaving keloid-like scars. About her twelfth year the patient had an eruption upon the left arm; in her thirteenth year one upon the leg; and since her twentieth year the attacks have recurred annually. The functions of the cerebral nerves, muscles, reflexes, etc., were normal. Hyperalgesia begins at the left axillary region and extends down to the edge of the ribs. At the gangrenous points anæsthesia is present.

Case 2, a fifteen-year-old servant girl, appeared February 14, 1887. Upon the left cheek vesicles followed the application of a strong ointment. There were hemianæsthesia and hemianalgesia. The left side of the body was not sensitive to the prick of a needle, even when applied through the thickness of the skin. Faradization of the skin with a strong current was not painful, but stroking of the nerves was. Case 3, a woman, aged 24, came under care in 1887. The eruption appeared upon the forearm.

Case 4, a man, in 1887, had an eruption upon the volar surface of the left arm.

In commenting upon these cases Kaposi refers to the fact that the loss of substance and the keloid-like scars are not unlike artificial conditions from application of strong medicaments like caustic potash, nitric acid, etc. This was particularly so in the second case, where granulations were present and all the attendant features. In all the cases it seems that the process was similar to the late appearances upon the forearm. It would be hardly proper to attribute the condition to any extraneous cause, for destruction of the papillary bodies and the corium occurs before the epithelium is destroyed. Through the contents of the vesicles the process of necrotic change is seen, so that artificial disturbance can be excluded. The question arises: Is

* Wiener Med. Wochenschrift, 1894.

† Archiv für Dermatologie und Syphilis, 1889.

this a spontaneous gangrene of a neurotic and hysteric origin? Zosters are in their etiology neurotic affections which the histological researches of Baerensprung, Rayer, Wiedman, etc., show to be due to diseases of the spinal ganglia and of the corresponding nerves. Kaposi does not discuss the question whether the vaso-motor nerves alone, or the hypothetical trophic nerves, are affected. In the gangrenous forms of zoster, there is not alone a disease of the spinal ganglia, but also an affection of the vaso-motor centres of the spinal cord itself.

H. Staub,* under the title of "Causes of Atypical Herpes Zoster,” reports a case of a sixteen-year-old girl suffering from a similar condition, the case being under observation since 1882. The diseased area was excised in 1893. A description of the excised portion is published by Klebs, from which the following extract is made: "There appears necrosis; this is followed by tissue hyperplasia or new growths. The new tissue growths are more marked the longer the condition has existed. Soon the ulcers, crater-like in appearance, begin to have the character of a sarcoma, in that these changes may penetrate further into the underlying tissues until even perforations into the larger cavities of the body may occur. On the other hand, the later ulcerations often show hardly a trace of tissue change. I have been able, both by microscopic and bacteriological examinations, to convince myself that in this case bacteria are not an etiological factor. But it is more difficult to determine the cause of the necrosis. If the destructive condition of the new tissue proliferation is to be taken into consideration, we have through this only a description of the actual condition; it then becomes necessary to decide upon what these destructive changes rest. In the more advanced cases, where the sarcoma-like cellular proliferation with dilated blood-vessels is found, the formation of a white thrombus can often be demonstrated; but this is not general enough to be accepted as a common cause, and is not present in the early stages, so that, reasoning by a process of exclusion, there can be nothing but a disturbance of the nerve influence. Unfortunately it was not possible in many of the extirpated ulcerations to determine this point. There is a markedly noticeable difficulty in ascertaining ⚫ the presence of nerves in the extirpated skin, and I think they are either absent or poorly developed. Again, the appearance of the process is identical with that of herpes zoster, in which a large number of careful investigators have shown marked changes in the nerve-trunks themselves."

It will be seen by the above report how unsatisfactory is the

* Archiv für Dermatologie und Syphilis, 1892.

Die Allg. Pathologie, vol. ii (Theil, Jena, 1889), pp. 38-39.