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To the Editor.— I found the report by Auletta and Headington 1 on the relation between purpura fulminans and congenital or acquired severe protein C deficiency most illuminating in a realm that had been murky before. Several additional questions arise. First, what are the histopathologic findings of the early blanchable lesions, or of those skin lesions that resolve spontaneously, quickly, and without scarring? It would be hard to invoke significant red blood cell extravasation with these features. Could there be a reactive dilatation of thrombus-free or at least unoccluded cutaneous arterioles and venules near those filled with fibrin thrombi? Is there significant cutaneous edema, perhaps from the same mechanism, in watershed zones that do not ultimately suffer intracutaneous and subcutaneous hemorrhage and cutaneous necrosis? Have biopsies ever been performed on early or nonprogressive lesions, either in human patients or in an animal model and, if so, what have they shown?

H. McC., aged 2, was brought to Children's Hospital at Denver from Lead, S. D., with a history of having swallowed a jackstone one week previously. Two unsuccessful attempts to remove the foreign body had been made, and as a result the boy was in a serious condition, with high fever and rapid pulse. Physicial examination showed interstitial emphysema of the neck and of the supraclavicular fossae, with some mottling of the skin in the latter regions due to subcutaneous hemorrhage, presumably from a laceration in the esophagus. Roentgenograms showed the presence of a jackstone in the esophagus at the level of the manubrium. Mediastinal emphysema was seen to be present, extending downward around and below the heart and upward into the neck. Roentgenograms taken subsequently, after the patient had ingested a small amount of barium sulfate, showed evidence of an opening in the esophagus, with some of the swallowed

To the Editor.— Although this is an important finding, most pigmented nail bands seen in clinical practice are due to less esoteric causes. A host of factors can be related to local or diffuse discoloration of the nail bed or nail plate, and many of these have characteristic physical findings. Subcutaneous hemorrhage, the most common cause of darkening of part of a nail, is usually accompanied by a history of pain or trauma. Pigmentation of the nail caused by chromogenic fungae is accompanied by onycholysis. Multiple bands can be seen in patients with Peutz-Jeghers syndrome1,2and some drugs, such as antimalarials, can produce longitudinal pigmentation in the nail bed. Increase in melanin in the nail bed is also seen with vitamin B12deficiency3and pinta.4 Narrow pigmented bands which extend from the proximal nail fold to the distal free edge in an otherwise normal nail suggest

To the Editor.— Hemophilia is an inherited defect in coagulation characterized by persistent bleeding following trauma. Hemarthrosis represents the most characteristic type of hemorrhage but bleeding also frequently occurs from the mouth, gums, lips, tongue, gastrointestinal tract, lungs, and even intracranially. 1,2 The skin may be involved with subcutaneous hemorrhage which spreads rapidly over the body. We are unaware of any report regarding acne as a potential source of bleeding in this disease. Recently, we have done follow-up studies on two brothers with classical hemophilia, one of whom experienced prolonged bleeding into nodular cystic lesions of acne. Report of a Case A 17-year-old white boy with a one year history of progressively severe acne involving his face, shoulders, and back was referred to the Acne Clinic of the Hospital of the University of Pennsylvania. The patient also suffered from hemophilia A with a factor VIII level of less than