garis) have been confirmed histologi¬ cally in both patients. This brings the total of such three.
cases on our
record to
Kaposi sarcoma should probably be added to those conditions, such as
Hodgkin disease, multiple myeloma, cancer of the lung, cancer of the breast, sarcoidosis etc, in which sec¬ ondary ichthyosis is bound to occur. Anatol Krakowski, MD Sarah Brenner, MD Joseph Covo, MD Tel Aviv, Israel
Spiny Palmar Keratosis To the Editor.\p=m-\Dobsonet al1 wrote of increased incidence of palmar keratoses in patients with various internal malignant diseases. This finding was disputed by Bean et al,2 who suggest that exposure to the carcinogenic effects of arsenicals could possibly explain the coincidence. The hyperkeratosis these authors describe is in the form of flat or rounded papules on the palms, especially involving the thenar and hypothenar eminences.3 We have recently seen a patient with unusual keratotic lesions who also had malignant carcinoma. Report of a Case.\p=m-\A65-year-old woman
shelled out. No erythema or tenderness was noted. Similar but less densely placed papules were also found on the palms, sparing the creases, and the toes. Unfortu¬ nately, the patient died before a biopsy
performed.
was
Comment.-Our patient's papules differ from those previously described by being spiny rather than flat or round, and by being present on the pulps of the distal phalanges rather than on the palms only. These lesions were also present on the toes. We are interested to know if others have seen similar spiny papules of the fingertips and toes, either associated with internal malignant disease or not.
Sidney Barsky, MD Sammy A. Hutman, MD
an
receiving therapy
for an advanced bronchogenic carcinoma that had been diagnosed seven months earlier. Six weeks before examination, she noted the development of small "spines" on her hands that were annoying but were otherwise asymptomatic. She had no history of psoriasis, Darier disease, or other skin disease, and denied exposure to arsenicals. The patient had had a mastectomy 26 years previously for breast carcinoma. Examination showed skin-colored to translucent spiny protrusions, about 1 to 2 mm high, on the ventral surfaces of all dis¬ tal phalanges of the hands (Figure). These protrusions were hard and could not be was
Spiny protrusions, 1 to 2 mm high, on ventral surfaces of distal phalanges of hands.
Chicago
1. Dobson RL, Young MR, Pinto JS: Palmar keratoses and cancer. Arch Dermatol 92:553-558, 1965. 2. Bean SF, Foxley EG, Fusaro RM: Palmar keratoses and internal malignancy: A negative study. Arch Dermatol 97:528-532, 1968. 3. Braverman IM: Skin Signs of Systemic Disease. Philadelphia, WB Saunders Co, 1970.
Malignant Melanoma
From
Thermal Burn Scar
To the Editor.\p=m-\We wish to report a of malignant melanoma that arose in an occupationally related thermal burn scar. To our knowledge, there have been no prior reports of the development of a malignant melanoma in a thermal burn scar in the literature, based on our own review and that of the American Medical Association's staff (personal communication, George X. Trimble, MD, case
May 17, 1974).
Report of a Case.\p=m-\A47-year-old, blue\x=req-\ eyed, light-complexioned fireman sustained burns over 40% of his body surface on May 5, 1964, when gasoline exploded in a fire he was fighting, igniting his clothes and skin. First and second degree burns were especially severe on the lower limbs. All burns healed without the need for skin
grafting. In 1966, he first noted a pigmented growth on the upper outer part of the right leg in the center of one of the healed burn scars. No prior pigmented spot at that site was recalled.
In mid 1973, there ment of the
ule
was
excised
logically, it
obvious enlarge¬ 1- to 2-cm nod¬ Nov 13, 1973. Histo¬ was
growth, and on
was a
a
malignant melanoma,
nodular type, with invasion to level IV of the reticular dermis. A week later, exten¬ sive local excision and grafting was done. No tumor was found in the tissue removed
Downloaded From: http://archderm.jamanetwork.com/ by a University of Calgary User on 05/28/2015
at the second excision.
On May 30, 1974, because of an enlarge¬ right groin, he had a right in¬ guinal and groin dissection and explora¬ tion of retroperitoneal nodes. Two inguinal nodes were positive for malignant mela¬ noma; 19 others were normal. Since August 1974, he has been included in a protocol immunotherapy study at the Melanoma Clinical Cooperative Group Clinic in the Department of Dermatology of the Uni¬ versity of California, San Francisco. The patient remains well and grossly tu¬ mor-free as of Feb 1975. He has been working full time as a fireman since Sept 1974. He has had no other skin cancers, and no family members have had any malig¬ nant neoplasms of the skin. ment of the
Comment.—It is recognized that burn scars may lead to skin cancer, al¬ though such a transformation is un¬ common. Trêves and Pack found that 2% of 1,091 squamous cell carcinomas developed from bum scars, and 0.5% of 1,374 basal cell epitheliomas arose in burn scars.1 They had no cases of malignant melanomas arising in a burn scar. In the modern scientific lit¬ erature, the first report of skin cancer arising in a bum scar was by an En¬ glish surgeon, Hawkins, in 1825.1 The cancers that have arisen in burn scars have been predominantly squamous cell carcinomas.2-3 A much smaller percentage have been adenocarcinomas, basal cell epitheliomas, and fibrosarcomas.1 Trauma is recognized as a factor in the formation of a malignant neo¬ plasm on the skin or soft tissues, or subjacent bone.45 Trauma may be single, blunt, physical, chemical, ther¬ mal, or chronic and repetitive.5 Skep¬ ticism has been reflected in several articles on the causal relationship of trauma to oncogenesis. Two recent reports discounted the speculation that trauma could induce formation of a malignant melanoma.6'7 How¬ ever, a statistical study in England concluded that "the relationship of trauma to the production of malig¬ nant melanoma of the skin is re¬ garded as established beyond reason¬ able doubt."8 (Burns were not mentioned, however). Reports have been published of malignant mela¬ nomas arising in such injuries as within a tattoo," a puncture wound by an indelible pencil,10 and within vacci¬ nation scars.11 The causal role of heat and wood smoke to induce malignant melanomas on the feet in black Afri¬ cans in Uganda has recently been suggested.12 Sunlight has also been
imputed, especially for lentigo malig¬ arising on sun-ex¬ posed skin.13 It has been shown in epidemiological studies that malignant melanoma arises more often than by chance alone in light-complexioned, blueeyed Caucasians, as in this case.14 However, no antecedent mole was re¬ nant melanomas
called at the site of the thermal bum and subsequent malignant mela¬ noma. On July 26, 1974, the Work¬ men's Compensation Board of the State of California adjudicated that the malignant melanoma in this fire¬ man was industrially caused, and not a coincidence. This is a precedent case. The decision was surely based on the legal phrase "in dubio semper pro laseo,"—"when in doubt, favor the
injured."15
Gerald A. Gellin, MD William L. Epstein, MD San Francisco
This study was supported in part by grant RIO CA13671-03 from the National Institutes of Health. 1. Treves N, Pack GT: The development of in burn scars. Surg Gynecol Obstet 53:749\x=req-\ 782, 1930. 2. Arons MS, Lynch JB, Lewis SR, et al: Scar tissue carcinoma: I. A clinical study with special reference to burn scar carcinoma. Ann Surg 161:170-188, 1965. 3. Bowers RF, Young JM: Carcinomas arising in scars, osteomyelitis, and fistulae. Arch Surg 80:564-570, 1960. 4. Cowdry EV: Etiology and Prevention of Cancer in Man. New York, Appleton-Century\x=req-\ Crofts, 1968, p 253. 5. Warren S: Minimal criteria required to prove causation of traumatic or occupational neoplasms. Ann Surg 117:585-595, 1943. 6. Jackson R: Myths of cutaneous malignant melanoma. Laval Med 42:921-925, 1971. 7. Attie JN, Khafif RA: Melanotic Tumors\p=m-\ Biology, Pathology and Clinical Features. Springfield, Ill, Charles C Thomas Publishers, 1964, pp 175-178. 8. Lea AJ: Malignant melanomas of the skin: The relationship of trauma. Ann R Coll Surg Engl 37:169-176, 1965. 9. Kirsch N: Malignant melanoma developing in a tattoo. Arch Dermatol 99:596-598, 1969. 10. Sharlit H: Melanoma caused by indelible pencil. Arch Dermatol Syphilol 37:301-306, 1938. 11. Marmelzat WL, Hirsch P, Martel S: Malignant melanomas in smallpox vaccination scars: Report of six cases. Arch Dermatol 89:823-826, 1964. 12. Lewis MG: Malignant melanoma in Uganda (The relationship between pigmentation and malignant melanoma on the soles of the feet). Brit J Cancer 21:483-495, 1967. 13. Ward WH: Melanoma: Carcinoma of the skin and sunlight. Aust J Dermatol 9:70-75,1967. 14. Gellin GA, Kopf AW, Garfinkel L: Malignant melanoma: A controlled study of possibly associated factors. Arch Dermatol 99:43-48,1969. 15. Monkman GR, Orwoll G, Ivins JC: Trauma and oncogenesis. Mayo Clin Proc 49:157-163, 1974. cancer
Acute
Eruptive Darier
Disease
To the Editor.\p=m-\Thearticle in the Arby Dr. Harold Fishman reporting a case of acute eruptive Darier disease1 is as interesting as it is curious. If in fact his patient had Darier disease, it would be, as Dr. Fishman says, very unusual. It seems more likely that his patient had transient acantholytic dermatosis,2 which is manifested by the same clinical and histological findings as those reported by Fishman. Inasmuch as the lesions were clinically follicular, it is possible that the patient had folliculitis with focal acantholytic dyskeratosis.3 No follicle was presented in the article. Finally, we were not given any information about the patient's medical chives
history (state of health, medications, routine or occasional topical skin care, etc). In view of the patient's benign course, his seeming response to fluocinonide (Lidex) cream, and the fact
that other entities were not excluded, it seems presumptuous to accept this as a case of acute eruptive Darier disease. Lawrence Sherwin, MD Santa Ana, Calif
Acute, eruptive Darier dis(keratosis follicularis): Occurrence in an adult. Arch Dermatol 111:221-222, 1975. 1. Fishman HC:
ease
2. Grover RW: Transient acantholytic dermatosis. Arch Dermatol 101:426-434, 1970. 3. Ackerman AB: Focal acantholytic dyskeratosis. Arch Dermatol 106:702-706, 1972.
Reply To the Editor.\p=m-\Inanswer to the letSherwin, my patient is in excellent health and was using no medication at all at the onset of his dermatosis, which in no way resembled a folliculitis. Other entities were considered and excluded. Of course, Dr. Sherwin is entitled to his opinion. However, several similar cases have been reported, including three cases by Dr. Victor Witten, known personally by many of us as a very competent observer. Moreover, the slides were reviewed very carefully by Dr. Paul Hirsch, an extremely knowledgeable dermatopathologist, who concurs with the ter from Dr. Lawrence
diagnosis
as
presented.
Harold C. Fishman, MD Los Angeles
A Solecism
To the Editor.\p=m-\Inan article in a reArchives, "scabie" is given as the singular form of scabies. Since this spelling occurs twice, this cent issue of the
Downloaded From: http://archderm.jamanetwork.com/ by a University of Calgary User on 05/28/2015
is not a typographical error but a solecism. Latin did not consistently form plurals by adding "s." This was true for nouns of the fourth and fifth declensions, but true only for masculine and feminine forms of the nouns of the third declension. Neuter nouns of the second and third declensions ended in "a," masculine nouns of the second declension ended in "i," and all nouns of the first declension ended in "ae." Reference to Lewis and Short's A Latin Dictionary (Oxford, England, Clarendon Press, 1966) confirms that the word is singular. On p 1637, one reads, "scabies . in particular, as a disease, the scab, mange, itch . an .
.
.
.
itching, longing, pruriency."
Moreover, "anu" is not the singular form of anus, and Bacchus and Venus
are
individuals,
not groups.
Vincent J. Derbes, MD New Orleans
Of Fleas and Foxes To the Editor.\p=m-\Theinteresting report titled "An Epidemic of Canine Scabies in Man" by Charlesworth and Johnson that appeared in the Archives (110:572, 1974) brings to mind another incident of infestations brought to man through his "best friend" or, to be exact, the best friend's cousin. A large local county hospital provides day nursery facilities for the children of the employees. The wooden building that houses the nursery, is placed, for some reason, on an artificial elevation through which passes a small tunnel containing two large pipes from the central heating plant. Over the years, the netting blocking the entry to the tunnel had fallen into a state of disrepair, and a family of foxes had availed themselves of the opportunity to build a comfortable nest in the tunnel directly under the nursery. From the nearby maternity ward, the foxes and their cubs had been observed in the spring playing in the early morning sun in the sand box belonging to the nursery. This idyllic scene must have aroused feelings of companionship and sympathy in the new mothers and the personnel of the maternity ward, since the observa¬ tion was not reported to the hospi¬
tal management. The presence of the foxes remained unknown to the per¬ sonnel of the day nursery for a while, since the family of foxes always had
cases on our
record to
Kaposi sarcoma should probably be added to those conditions, such as
Hodgkin disease, multiple myeloma, cancer of the lung, cancer of the breast, sarcoidosis etc, in which sec¬ ondary ichthyosis is bound to occur. Anatol Krakowski, MD Sarah Brenner, MD Joseph Covo, MD Tel Aviv, Israel
Spiny Palmar Keratosis To the Editor.\p=m-\Dobsonet al1 wrote of increased incidence of palmar keratoses in patients with various internal malignant diseases. This finding was disputed by Bean et al,2 who suggest that exposure to the carcinogenic effects of arsenicals could possibly explain the coincidence. The hyperkeratosis these authors describe is in the form of flat or rounded papules on the palms, especially involving the thenar and hypothenar eminences.3 We have recently seen a patient with unusual keratotic lesions who also had malignant carcinoma. Report of a Case.\p=m-\A65-year-old woman
shelled out. No erythema or tenderness was noted. Similar but less densely placed papules were also found on the palms, sparing the creases, and the toes. Unfortu¬ nately, the patient died before a biopsy
performed.
was
Comment.-Our patient's papules differ from those previously described by being spiny rather than flat or round, and by being present on the pulps of the distal phalanges rather than on the palms only. These lesions were also present on the toes. We are interested to know if others have seen similar spiny papules of the fingertips and toes, either associated with internal malignant disease or not.
Sidney Barsky, MD Sammy A. Hutman, MD
an
receiving therapy
for an advanced bronchogenic carcinoma that had been diagnosed seven months earlier. Six weeks before examination, she noted the development of small "spines" on her hands that were annoying but were otherwise asymptomatic. She had no history of psoriasis, Darier disease, or other skin disease, and denied exposure to arsenicals. The patient had had a mastectomy 26 years previously for breast carcinoma. Examination showed skin-colored to translucent spiny protrusions, about 1 to 2 mm high, on the ventral surfaces of all dis¬ tal phalanges of the hands (Figure). These protrusions were hard and could not be was
Spiny protrusions, 1 to 2 mm high, on ventral surfaces of distal phalanges of hands.
Chicago
1. Dobson RL, Young MR, Pinto JS: Palmar keratoses and cancer. Arch Dermatol 92:553-558, 1965. 2. Bean SF, Foxley EG, Fusaro RM: Palmar keratoses and internal malignancy: A negative study. Arch Dermatol 97:528-532, 1968. 3. Braverman IM: Skin Signs of Systemic Disease. Philadelphia, WB Saunders Co, 1970.
Malignant Melanoma
From
Thermal Burn Scar
To the Editor.\p=m-\We wish to report a of malignant melanoma that arose in an occupationally related thermal burn scar. To our knowledge, there have been no prior reports of the development of a malignant melanoma in a thermal burn scar in the literature, based on our own review and that of the American Medical Association's staff (personal communication, George X. Trimble, MD, case
May 17, 1974).
Report of a Case.\p=m-\A47-year-old, blue\x=req-\ eyed, light-complexioned fireman sustained burns over 40% of his body surface on May 5, 1964, when gasoline exploded in a fire he was fighting, igniting his clothes and skin. First and second degree burns were especially severe on the lower limbs. All burns healed without the need for skin
grafting. In 1966, he first noted a pigmented growth on the upper outer part of the right leg in the center of one of the healed burn scars. No prior pigmented spot at that site was recalled.
In mid 1973, there ment of the
ule
was
excised
logically, it
obvious enlarge¬ 1- to 2-cm nod¬ Nov 13, 1973. Histo¬ was
growth, and on
was a
a
malignant melanoma,
nodular type, with invasion to level IV of the reticular dermis. A week later, exten¬ sive local excision and grafting was done. No tumor was found in the tissue removed
Downloaded From: http://archderm.jamanetwork.com/ by a University of Calgary User on 05/28/2015
at the second excision.
On May 30, 1974, because of an enlarge¬ right groin, he had a right in¬ guinal and groin dissection and explora¬ tion of retroperitoneal nodes. Two inguinal nodes were positive for malignant mela¬ noma; 19 others were normal. Since August 1974, he has been included in a protocol immunotherapy study at the Melanoma Clinical Cooperative Group Clinic in the Department of Dermatology of the Uni¬ versity of California, San Francisco. The patient remains well and grossly tu¬ mor-free as of Feb 1975. He has been working full time as a fireman since Sept 1974. He has had no other skin cancers, and no family members have had any malig¬ nant neoplasms of the skin. ment of the
Comment.—It is recognized that burn scars may lead to skin cancer, al¬ though such a transformation is un¬ common. Trêves and Pack found that 2% of 1,091 squamous cell carcinomas developed from bum scars, and 0.5% of 1,374 basal cell epitheliomas arose in burn scars.1 They had no cases of malignant melanomas arising in a burn scar. In the modern scientific lit¬ erature, the first report of skin cancer arising in a bum scar was by an En¬ glish surgeon, Hawkins, in 1825.1 The cancers that have arisen in burn scars have been predominantly squamous cell carcinomas.2-3 A much smaller percentage have been adenocarcinomas, basal cell epitheliomas, and fibrosarcomas.1 Trauma is recognized as a factor in the formation of a malignant neo¬ plasm on the skin or soft tissues, or subjacent bone.45 Trauma may be single, blunt, physical, chemical, ther¬ mal, or chronic and repetitive.5 Skep¬ ticism has been reflected in several articles on the causal relationship of trauma to oncogenesis. Two recent reports discounted the speculation that trauma could induce formation of a malignant melanoma.6'7 How¬ ever, a statistical study in England concluded that "the relationship of trauma to the production of malig¬ nant melanoma of the skin is re¬ garded as established beyond reason¬ able doubt."8 (Burns were not mentioned, however). Reports have been published of malignant mela¬ nomas arising in such injuries as within a tattoo," a puncture wound by an indelible pencil,10 and within vacci¬ nation scars.11 The causal role of heat and wood smoke to induce malignant melanomas on the feet in black Afri¬ cans in Uganda has recently been suggested.12 Sunlight has also been
imputed, especially for lentigo malig¬ arising on sun-ex¬ posed skin.13 It has been shown in epidemiological studies that malignant melanoma arises more often than by chance alone in light-complexioned, blueeyed Caucasians, as in this case.14 However, no antecedent mole was re¬ nant melanomas
called at the site of the thermal bum and subsequent malignant mela¬ noma. On July 26, 1974, the Work¬ men's Compensation Board of the State of California adjudicated that the malignant melanoma in this fire¬ man was industrially caused, and not a coincidence. This is a precedent case. The decision was surely based on the legal phrase "in dubio semper pro laseo,"—"when in doubt, favor the
injured."15
Gerald A. Gellin, MD William L. Epstein, MD San Francisco
This study was supported in part by grant RIO CA13671-03 from the National Institutes of Health. 1. Treves N, Pack GT: The development of in burn scars. Surg Gynecol Obstet 53:749\x=req-\ 782, 1930. 2. Arons MS, Lynch JB, Lewis SR, et al: Scar tissue carcinoma: I. A clinical study with special reference to burn scar carcinoma. Ann Surg 161:170-188, 1965. 3. Bowers RF, Young JM: Carcinomas arising in scars, osteomyelitis, and fistulae. Arch Surg 80:564-570, 1960. 4. Cowdry EV: Etiology and Prevention of Cancer in Man. New York, Appleton-Century\x=req-\ Crofts, 1968, p 253. 5. Warren S: Minimal criteria required to prove causation of traumatic or occupational neoplasms. Ann Surg 117:585-595, 1943. 6. Jackson R: Myths of cutaneous malignant melanoma. Laval Med 42:921-925, 1971. 7. Attie JN, Khafif RA: Melanotic Tumors\p=m-\ Biology, Pathology and Clinical Features. Springfield, Ill, Charles C Thomas Publishers, 1964, pp 175-178. 8. Lea AJ: Malignant melanomas of the skin: The relationship of trauma. Ann R Coll Surg Engl 37:169-176, 1965. 9. Kirsch N: Malignant melanoma developing in a tattoo. Arch Dermatol 99:596-598, 1969. 10. Sharlit H: Melanoma caused by indelible pencil. Arch Dermatol Syphilol 37:301-306, 1938. 11. Marmelzat WL, Hirsch P, Martel S: Malignant melanomas in smallpox vaccination scars: Report of six cases. Arch Dermatol 89:823-826, 1964. 12. Lewis MG: Malignant melanoma in Uganda (The relationship between pigmentation and malignant melanoma on the soles of the feet). Brit J Cancer 21:483-495, 1967. 13. Ward WH: Melanoma: Carcinoma of the skin and sunlight. Aust J Dermatol 9:70-75,1967. 14. Gellin GA, Kopf AW, Garfinkel L: Malignant melanoma: A controlled study of possibly associated factors. Arch Dermatol 99:43-48,1969. 15. Monkman GR, Orwoll G, Ivins JC: Trauma and oncogenesis. Mayo Clin Proc 49:157-163, 1974. cancer
Acute
Eruptive Darier
Disease
To the Editor.\p=m-\Thearticle in the Arby Dr. Harold Fishman reporting a case of acute eruptive Darier disease1 is as interesting as it is curious. If in fact his patient had Darier disease, it would be, as Dr. Fishman says, very unusual. It seems more likely that his patient had transient acantholytic dermatosis,2 which is manifested by the same clinical and histological findings as those reported by Fishman. Inasmuch as the lesions were clinically follicular, it is possible that the patient had folliculitis with focal acantholytic dyskeratosis.3 No follicle was presented in the article. Finally, we were not given any information about the patient's medical chives
history (state of health, medications, routine or occasional topical skin care, etc). In view of the patient's benign course, his seeming response to fluocinonide (Lidex) cream, and the fact
that other entities were not excluded, it seems presumptuous to accept this as a case of acute eruptive Darier disease. Lawrence Sherwin, MD Santa Ana, Calif
Acute, eruptive Darier dis(keratosis follicularis): Occurrence in an adult. Arch Dermatol 111:221-222, 1975. 1. Fishman HC:
ease
2. Grover RW: Transient acantholytic dermatosis. Arch Dermatol 101:426-434, 1970. 3. Ackerman AB: Focal acantholytic dyskeratosis. Arch Dermatol 106:702-706, 1972.
Reply To the Editor.\p=m-\Inanswer to the letSherwin, my patient is in excellent health and was using no medication at all at the onset of his dermatosis, which in no way resembled a folliculitis. Other entities were considered and excluded. Of course, Dr. Sherwin is entitled to his opinion. However, several similar cases have been reported, including three cases by Dr. Victor Witten, known personally by many of us as a very competent observer. Moreover, the slides were reviewed very carefully by Dr. Paul Hirsch, an extremely knowledgeable dermatopathologist, who concurs with the ter from Dr. Lawrence
diagnosis
as
presented.
Harold C. Fishman, MD Los Angeles
A Solecism
To the Editor.\p=m-\Inan article in a reArchives, "scabie" is given as the singular form of scabies. Since this spelling occurs twice, this cent issue of the
Downloaded From: http://archderm.jamanetwork.com/ by a University of Calgary User on 05/28/2015
is not a typographical error but a solecism. Latin did not consistently form plurals by adding "s." This was true for nouns of the fourth and fifth declensions, but true only for masculine and feminine forms of the nouns of the third declension. Neuter nouns of the second and third declensions ended in "a," masculine nouns of the second declension ended in "i," and all nouns of the first declension ended in "ae." Reference to Lewis and Short's A Latin Dictionary (Oxford, England, Clarendon Press, 1966) confirms that the word is singular. On p 1637, one reads, "scabies . in particular, as a disease, the scab, mange, itch . an .
.
.
.
itching, longing, pruriency."
Moreover, "anu" is not the singular form of anus, and Bacchus and Venus
are
individuals,
not groups.
Vincent J. Derbes, MD New Orleans
Of Fleas and Foxes To the Editor.\p=m-\Theinteresting report titled "An Epidemic of Canine Scabies in Man" by Charlesworth and Johnson that appeared in the Archives (110:572, 1974) brings to mind another incident of infestations brought to man through his "best friend" or, to be exact, the best friend's cousin. A large local county hospital provides day nursery facilities for the children of the employees. The wooden building that houses the nursery, is placed, for some reason, on an artificial elevation through which passes a small tunnel containing two large pipes from the central heating plant. Over the years, the netting blocking the entry to the tunnel had fallen into a state of disrepair, and a family of foxes had availed themselves of the opportunity to build a comfortable nest in the tunnel directly under the nursery. From the nearby maternity ward, the foxes and their cubs had been observed in the spring playing in the early morning sun in the sand box belonging to the nursery. This idyllic scene must have aroused feelings of companionship and sympathy in the new mothers and the personnel of the maternity ward, since the observa¬ tion was not reported to the hospi¬
tal management. The presence of the foxes remained unknown to the per¬ sonnel of the day nursery for a while, since the family of foxes always had
