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A TEXT-BOOK 
 
 DERMATOLOGY 
 
 BY 
 
 J. DARIER 
 
 PHYSICIAN TO THE HOPITAL SAINT-LOUIS, MEMBER OF THE ACADEMY OF MEDICINE, PARIS, 
 FRANCE ; HONORARY MEMBER OF THE AMERICAN DERMATOLOGICAL ASSOCIATION, ETC. 
 
 AUTHORIZED TRANSLATION FROM THE SECOND FRENCH EDITION 
 
 Edited with Notes by 
 
 S. POLLITZER 
 
 NEW YORK 
 
 EX-PRESIDENT OF THE AMERICAN DERMATOLOGICAL ASSOCIATION; CORRESPONDING 
 
 MEMBER OF THE FRENCH SOCIETY OF DERMATOLOGY AND SYPHILOGRAPHY, ETC. 
 
 ILLUSTRATED WITH 204 ENGRAVINGS AND 
 4 COLORED PLATES 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AND NEW YORK 
 1920 
 
Copyright 
 
 LEA & FEBIGER 
 
 1920 
 
 MAR -4 1920 
 
 g)CU559932 
 
 
PREFACE TO THE SECOND EDITION. 
 
 The first edition of this book was exhausted several years ago. 
 The Great War for some time absorbed all our activities and all 
 our thoughts. But the time has come to think of the young physi- 
 cians returning from the armies and make ready the means for 
 facilitating the work they are called upon to perform. I have 
 accordingly prepared this second edition, in spite of the difficulties 
 of these troublous times. I have insisted upon its being entirely 
 abreast of the progress of science and as complete as possible 
 without unnecessary details. The general plan of the book, which 
 has been tested and found to possess real didactic advantages has, 
 of course, been retained. 
 
 Many paragraphs have required rewriting and more or less con- 
 siderable elaboration. Among these may be mentioned those deal- 
 ing with anaphylaxis, phagedena, the sarcoids, the gangrenes, the 
 cutaneous atrophies, inguinal epidermophytosis and the derm ato- 
 my coses. The review of the general interpretation of tubercu- 
 losis, congenital syphilis and the xanthomata has had to undergo 
 notable modifications; paragraphs or new chapters have been devoted 
 to the dyskeratoses, cutaneous diphtheria, the leishmanioses, the 
 cutaneous leukemias, the tophi of gout, etc. The introduction of 
 the serodiagnosis of syphilis and the treatment with the arseno- 
 benzols into daily practice has demanded the allotment of con- 
 siderable space to these subjects. Finally, in rewriting the 
 therapeutic notes, I have endeavored to make them still more 
 practical and to emphasize the recommendations dictated by my 
 personal experience as to the choice of medication and the errors 
 to be avoided. 
 
 Professor Jadassohn, of Bern, has added to the German transla- 
 tion of this book which appeared under his direction in 1913, -a 
 considerable number of notes which I have carefully retained when- 
 
iv PREFACE TO THE SECOND EDITION 
 
 ever his suggestions seemed to me to be of value for the reader; 
 they have been incorporated in my text, of course, mentioning 
 their origin. 
 
 As it stands, this volume although rejuvenated and somewhat 
 better nourished, remains essentially the same as its predecessor. 
 I can only wish that it may meet with the same kind reception. 
 My excellent and devoted publishers have left nothing undone to 
 present it in good shape and I herewith express to them my sincere 
 and grateful acknowledgments. 
 
 J. Darier. 
 
EDITOR'S PREFACE. 
 
 In undertaking the task of editing Darier's Precis de Dermatologie 
 I have been actuated less by a personal friendship with the dis- 
 tinguished author extending over a period of thirty years, than by 
 a sense of the importance of introducing to the English-reading 
 student of dermatology a work that is in many respects unique 
 in its presentation of the subject and, as it seems to me, of extra- 
 ordinary value for the student and the teacher. 
 
 The plan of the work is fully explained in the author's introductory 
 chapter and needs no further comment. The German translation 
 of the first edition enjoyed the advantage of editorial comment at 
 the hands of one of the foremost dermatologists of our time, Pro- 
 fessor Jadassohn of Berne, and Darier has made use of these com- 
 ments in this the second edition of his Precis. In preparing the work for 
 English readers I have added notes which are enclosed in brackets, 
 [ ] to differentiate them from the author's text and which, in 
 the case of more extensive notes, are printed in a different style of 
 type. It need not be emphasized that they are not intended by 
 way of criticism: a few of them seemed to me desirable for the 
 elucidation of the text; some were suggested by conditions peculiar 
 to English and American practice and some convey my personal 
 experience in clinical dermatology. It can hardly be expected that 
 two dermatologists practicing their profession for thirty years in 
 different hemispheres will be of the same mind on all subjects. 
 
 There is no dearth of excellent treatises of dermatology in the 
 English language and this work may confidently be expected to find 
 its place beside them. The student cannot fail to profit from a study 
 of Darier's unusual power of delineation in brief compass, his pre- 
 sentation of clear-cut cameos of description, his obvious habit of 
 thinking of lesions in relation to their anatomical structure and 
 always with a background of general pathology. To these sufficient 
 
VI EDITOR'S PREFACE 
 
 reasons for producing another book may be added the author's 
 originality in the arrangement of his subject-matter and finally 
 the desirability of placing before English-reading students the views 
 of a foreign author, especially one who represents an old and honored 
 school of dermatology. 
 
 French dermatologists have played a leading role in the devel- 
 opment of our science. The Hopital Saint-Louis, the greatest 
 dermatological clinic in the world, has afforded an extraordinary 
 opportunity for study and for more than a century it has furnished 
 a succession of great dermatologists who have handed down their 
 experience from teacher to pupil in an unbroken chain. Berne, 
 Berlin, Breslau, Hamburg, London and many cities in America and 
 elsewhere have excellent dermatologists whose observations and 
 studies have greatly enriched our science; but in all these centers, 
 dermatology is the work of one man or of a number of independent 
 units. Vienna indeed furnishes an example of a school of derma- 
 tology that has exercised a powerful and lasting influence in its 
 field, lint Vienna was a one-man school and unfortunately the 
 great light shed by Ilebra so blinded his followers that for a gen- 
 eration the Vienna school suffered from a form of dermatological 
 amblyopia: neither Duhring's disease, for instance, nor pityriasis 
 rosea were recognized in Vienna as dermatological entities. French 
 dermatology is unique in the peculiar circumstance of a familiarity 
 with the great masters of the past that is almost personal. Alibert, 
 Cazenave, Biett, Devergie, Bazin, Vidal, Fournier, Besnier, seem 
 living personalities to the present-day student at the Saint-Louis. 
 The advantages derived from this local continuity of observation 
 and practice are inestimable. 
 
 There is, however, an inherent danger bound up with its advan- 
 tages; that is the danger of falling to too great an extent under the 
 influence of tradition. Forty years ago French dermatology was 
 suffering from the defects of its merits and it is only recently that 
 such conceptions as are implied in the terms herpetism, arthritism, 
 lynipliatism, etc., have ceased to sway French dermatological 
 thought and traces of these conceptions still linger in French 
 medical literature, side by side with the most advanced thought in 
 medical science. 
 
 Another possible effect of tradition may be found in the current 
 
EDITOR'S PREFACE Vll 
 
 French dermatotherapy. French physicians to a great extent 
 are in the habit of employing elaborate and complicated formulas 
 in their treatment of diseases. Most of these have the sanction of 
 long usage; some of them are even medieval in their construction. 
 French dermatologists probably have not less success in curing 
 their patients than those of other countries and it is surely not less 
 interesting than instructive to learn that there are various ways of 
 accomplishing this result. 
 
 The observant reader will be struck with the great preponderance 
 of references to achievements of French dermatologists. The 
 assumption that this is an illustration of a narrow spirit which is 
 out of place in a scientific work will be dispelled if the reader will 
 examine an English, American, German or Italian text-book from 
 the same point of view. He will find that this form of Chauvinism 
 is common to all nations and is indeed perfectly natural. An author 
 obviously will cite the literature with which he is most familiar 
 and which is most accessible to his readers. From this point of view 
 again it is an advantage to the English reader to become acquainted 
 with the work of a foreign author and thereby acquire a broader 
 outlook on his specialty. 
 
 The Editor ventures to express the hope that this work of Darier's 
 
 will be found not less useful to the reader than it has been instructive 
 
 and inspiring to him. 
 
 S. Pollitzer. 
 New York, 1920. 
 
CONTENTS. 
 
 Introduction 17 
 
 Morphology of the Dermatoses 17 
 
 Nosography of the Dermatoses 20 
 
 Therapeutic Notes 20 
 
 PART I. 
 MORPHOLOGY OF THE DERMATOSES. 
 
 CHAPTER I. 
 
 Erythema and the Erythemata 23 
 
 Intertrigo 30 
 
 Erythema Solare seu Actinicum 32 
 
 Erythema Pernio or Frost-bite 34 
 
 Acro-asphyxia and Livedo 36 
 
 Rosacea 36 
 
 Erythema Multiforme 39 
 
 Syphilitic Roseola 41 
 
 CHAPTER II. 
 
 Urticaria 43 
 
 Giant Urticaria 49 
 
 Urticaria Factitia, or Dermographism 49 
 
 CHAPTER III. 
 
 Purpura 52 
 
 Secondary Purpuras 54 
 
 Primary Purpuras 54 
 
CONTENTS 
 
 CHAPTER IV 
 
 Eczema (,0 
 
 • - • • 79 
 
 Artificial Eczemas 
 Infantile Eczemas 
 
 Secondary Eczematization §2 
 
 Eczematosis go 
 
 Dysidrosis gc 
 
 Acute Disseminated Eczema or Miliary Impetigo .... 87 
 
 CHAPTER V. 
 
 Eczematides 
 
 El{YTHEMATOTTS-SQUAMOUS DERMATOSES .... S9 
 
 102 
 
 Pityriasis Rosea of Gibert 
 
 Psoriasis 
 
 Parapsoriasis ,ji 
 
 Psoriatiform Syphilides ijq 
 
 Erythemato-squamous Epidermo-mycoses 114 
 
 CHAPTER VI. 
 
 Erythrodermas H5 
 
 Primary Erythrodermas Hg 
 
 Erythrodermic Dermatoses J20 
 
 Secondary Erythrodermas 12i 
 
 < fcragenital Erythrodermas and Erythrodermas of the Newborn 122 
 
 CHAPTER VII. 
 
 Papules and Papulae Dermatoses .... 127 
 
 Juvenile Mat Warts j.,q 
 
 Ldcherj Planus ,o. 
 
 Atypical Forms of Lichen Planus yi-j 
 
 Papules of Prurigo 140 
 
 Papular Syphilides I e> 
 
 Lichen Scrofulosorum j.r 
 
 chapter viii. 
 
 Vesicles and Vesicular Dermatoses . . 148 
 
 Her P es '. 150 
 
 Z,,n:i 154 
 
CONTENTS 
 
 CHAPTER IX. 
 
 Pustules and Pustular Dermatoses .... 160 
 
 Impetigo 162 
 
 Ecthyma 169 
 
 Pustules of the Infectious Chronic Dermatoses 172 
 
 CHAPTER X. 
 
 Bullae and Bullous Dermatoses 174 
 
 Accidentally Bullous Dermatoses 175 
 
 Bullous Impetigos 178 
 
 Pemphigus Acutus Febrilis Gravis 179 
 
 Recurrent Pemphigus, Duhring's Disease or Polymorphous Dermatitis . 179 
 
 Rare Dermatoses Related to Duhring's Disease 184 
 
 Chronic Pemphigus 186 
 
 Pemphigus Foliaceus 189 
 
 Congenital Pemphigus 191 
 
 Pemphigus Hystericus 192 
 
 CHAPTER XL 
 
 Keratoses 194 
 
 Kerosis 196 
 
 Pityriasis Simplex 19S 
 
 Ichthyosis 200 
 
 Ichthyosiform Hyperkeratoses 203 
 
 Circumscribed Keratoses 206 
 
 Keratoderma 211 
 
 Keratosis of Mucous Membranes . . .218 
 
 Dyskeratoses 230 
 
 CHAPTER XII. 
 
 Papillomatous and Proliferating Dermatoses . . . 237 
 
 Venereal Warts 238 
 
 Verruca Vulgaris 240 
 
 Papillary and Pigmentary Dystrophy or Acanthosis Nigricans . . . 242 
 
 Accidentally Proliferating Dermatoses 244 
 
 Proliferating Tropical Dermatoses 249 
 
 CHAPTER XIII. 
 
 Tubercles and Tuberculo-ulcerative Dermatoses . . 252 
 
 Tuberculo-Ulcerative Dermatoses 253 
 
 Tubercular Sypbilides 253 
 
 Lupus Tubercles 256 
 
 Tubercles of Leprosy 258 
 
 Cutaneous Sarcoids or Lupoid 259 
 
301 
 
 CONTENTS 
 
 CHAPTER XIV. 
 
 Nodes and Nodules 263 
 
 Nodular Dermatoses 263 
 
 leute Nodular Dermatoses 265 
 
 Gummas 266 
 
 Subacute Non-gummous Nodes 271 
 
 Sarcoids 272 
 
 CHAPTER XV. 
 
 In i rations, Ulcerative Dermatoses and Cutaneous Gangrenes 277 
 
 Ulceration in General 277 
 
 Acute Ulcerations 281 
 
 Subacute Ulcerations 284 
 
 Phagedena 293 
 
 Ulcers 296 
 
 Ulcerations of Mucous Membranes 303 
 
 Cutaneous Gangrene 312 
 
 CHAPTER XVI. 
 
 Dyschromias 320 
 
 Artificial ami Secondary Dyschromias 321 
 
 Associated Dyschromias or Dyschromic Dermatoses 323 
 
 Pigmentary Spots 323 
 
 Diffuse Dyschromias and Melanodermas 325 
 
 Vitiligo 329 
 
 Tattoo Marks and Argyria 332 
 
 CHAPTER XVII. 
 
 Ci i wi.ni - Atrophies, Scleroses and Dystrophies 
 
 < Beatrices 
 
 Linear and Macular At rophies 
 Idiopathic Atrophies 
 Sclerotic Atrophies in Spots 
 
 Scleroderma 
 
 Regional Atrophies and I termatoscleroses 
 ( lutaneous I dystrophies 
 
 334 
 336 
 341 
 343 
 346 
 347 
 353 
 355 
 
 CHAPTER XVIII. 
 
 Cutaneous Hypertrophies 360 
 
 Elephantiasis • 361 
 
 Non-elephantiastic Hypertrophies 371 
 
CONTENTS 
 
 CHAPTER XIX. 
 
 Folliculoses 376 
 
 Acute Suppurative Folliculitides 377 
 
 Seborrhea 383 
 
 The Acnes 384 
 
 Cicatricial Depilating Folliculitides 392 
 
 Subacute Folliculitides 395 
 
 Pityriasis Rubra Pilaris 399 
 
 Follicular Keratosis 401 
 
 CHAPTER XX. 
 
 Trichoses 404 
 
 Hypertrichoses 404 
 
 Alopecias 407 
 
 Dystrophic Trichoses • 416 
 
 Parasitic Trichoses 419 
 
 Trichomycoses 428 
 
 CHAPTER XXL 
 
 Onychoses 430 
 
 CHAPTER XXII. 
 
 HiDROSES 441 
 
 Functional Hidroses 442 
 
 Organic Hidroses 445 
 
 PART II. 
 NOSOLOGY OF THE DERMATOSES. 
 
 CHAPTER XXIII. 
 
 Artificial Dermatitides ...... 447 
 
 Dermatitides Due to Mechanical Causes 448 
 
 Dermatitides Due to Physical Causes 450 
 
 Toxidermas 456 
 
 Toxidermas from External Causes 463 
 
 Toxidermas from Internal Causes 471 
 
CONTENTS 
 
 CHAPTER XXIV 
 
 Neurodermatoses: Pruritus and Prurigo 481 
 
 Primary Pruritus 483 
 
 Prurigo 488 
 
 CHAPTER XXV. 
 
 Parasitic Dermatoses 502 
 
 Dermatoses Caused by Insects 502 
 
 Dermatoses Caused by Acari (Mites) 507 
 
 Dermatoses Caused by Worms and Larvae 514 
 
 Epklennoiiiycosos 515 
 
 CHAPTER XXVI. 
 
 [nfectious Dermatoses — Pyodermatitides . . 535 
 Pyodermatitides 536 
 
 CHAPTER XXVII. 
 
 Infectious Bacillary Dermatoses 546 
 
 Tuberculosis 546 
 
 Leprosy 578 
 
 Glanders 590 
 
 Verruga Peruana 593 
 
 Anthrax Malignant Pustule 593 
 
 ( Cutaneous Diphtheria 594 
 
 Soft Chancre 596 
 
 CHAPTEB XXVIII. 
 
 Dermatomycoses 599 
 
 Actinomycosis 599 
 
 .Mycetoma or Madura loot 602 
 
 Blastomycoses 603 
 
 Sporotrichoses 605 
 
 CHAPTEB XXLX. 
 
 l.\Ki:cTiors Dermatoses due to Protozoa . . . 610 
 
 Syphilis 610 
 
 Yaws 646 
 
 Leishmanioses 648 
 
CONTENTS 
 
 CHAPTER XXX. 
 
 Dermatoses of Leukemias and Analogous Pathological Conditions 651 
 
 Cutaneous Leukemias 651 
 
 Mycosis Fungoides 657 
 
 CHAPTER XXXI. 
 
 Tumors of the Skin 663 
 
 Nevi 664 
 
 Epithelial Tumors 669 
 
 Vascular and Connective-tissue Tumors 689 
 
 Sarcoma 706 
 
 APPENDIX. 
 
 Therapeutic Notes 711 
 
DISEASES OF THE SKIN. 
 
 INTRODUCTION. 
 
 This book is destined for new students entering a dermatological 
 service and for general practitioners whose hospital recollections 
 have become somewhat indistinct. My object has, therefore, been 
 to make it as concise and practical as possible, while including the 
 entire domain of cutaneous pathology. In order to make it short, 
 I have been obliged to sacrifice the entire bibliography, historical 
 references, quotations, learned discussions, etc., limiting myself to 
 the essential data from the standpoint of diagnosis and treatment. 
 In order to make it practical, it has seemed to me desirable to 
 arrange the material according to a plan which is not customary 
 and which I must first explain and justify. 
 
 MORPHOLOGY OF THE DERMATOSES. 
 
 In the first part (Chapters I to XXII) the eruptive lesions and 
 the non-eruptive cutaneous changes, namely, the elementary derma- 
 tological forms are discussed and to each of these a description of 
 the principal syndromes in which the elementary forms occur is 
 added. This requires some explanation. In dermatological prac- 
 tice, the physician is confronted by very peculiar conditions. He 
 does not have to look for pathological symptoms with the help of 
 more or less complicated devices; the symptoms present themselves 
 directly; he recognizes their features and their localization at once 
 and witnesses this development. Under these conditions it seems 
 obvious to me that a book intended to facilitate the study of skin 
 diseases should accord the first place to morphology, namely, to 
 what can be seen. In regard to the visible manifestations of cutan- 
 eous pathology, two contingencies are possible: the condition may 
 be an eruptive dermatosis, or the dermatosis under consideration 
 may be non-eruptive. 
 
 A. Eruptive Dermatoses. — This term is applied to skin diseases 
 made up of efflorescences, namely, spots, papules, vesicles, etc. 
 The analysis of every eruptive dermatosis must take up succes- 
 2 
 
IS DISEASES OF THE SKIN 
 
 sively four orders of facts: those relating to the efflorescence, to 
 the eruption, to the disease and to the patient. 
 
 1. The eruptive lesion deserves attention in the first place. This 
 is in reality merely the anatomical lesion of the dermatosis as it 
 appears to the naked eye. To inspect attentively an efflorescence, 
 to palpate it, to scratch it, to compress it under a glass slide, to 
 prick it with a needle so as accurately to determine its type — this 
 constitutes in a general way the naked-eye study of the pathological 
 anatomy. Conversely, it may be stated that to subject the efflores- 
 cence to biopsy for the purpose of studying its histology means its 
 clinical examination under the microscope. 
 
 The efflorescences are of fundamental importance; they really 
 represent the dermatologist's alphabet and no one ignorant of them 
 can learn to read the skin. 
 
 2. The eruption represents the efflorescences taken as a whole. 
 It is visible and all its features are in evidence; it is necessary to 
 note its abundance, its dissemination or its confluence, its topo- 
 graphical distribution, etc. 
 
 An eruption is said to be simple or pure when it is formed of 
 lesions of the same kind and of the same degree of development; it 
 is described as deformed, when the lesions are in different stages of 
 evolution; it is called complex or polymorphous when it is made up 
 of lesions of various types; complicated, when the primary lesions 
 become associated with other lesions secondary and of another kind. 
 
 :!. Information concerning the disease is usually furnished by 
 inquiry; it is necessary to ask about the mode of onset, the preced- 
 ing or accompanying circumstances, the extracutaneous symptoms, 
 the course, etc. Direct examination, however, will often permit a 
 series of data to be secured in this connection which will forestall the 
 patient's answers and serve to control their accuracy. 
 
 I. Among the conditions peculiar to the patient, some are of an 
 objective kind; for example, the sex, the age, the race and the con- 
 stitution of the individual. Information must also be obtained 
 in regard to his occupation, his hereditary, hygienic and pathologi- 
 cal antecedents, etc.; the viscera, body fluids and functions must be 
 reviewed; briefly, a general clinical examination be carried out in 
 order to ascertain the nature of the soil on which the skin disease 
 develops. 
 
 B. Non-eruptive Dermatoses.- In a second group of cases the 
 physician is not confronted with an eruption. The cutaneous 
 alterations may consist, for example, of a change in color of the 
 skin, or dyschromia; in hypertrophy or atrophy; in a lesion of the 
 nails, the hairs, etc. 
 
 This altered appearance of the integuments can sometimes be 
 referred with a high degree of probability to a definite inflamma- 
 
INTRODUCTION 19 
 
 tory, degenerative or dystrophic pathological process. In other cases, 
 however, it is impossible to determine the nature of the process. 
 It therefore seems preferable to me to depend on what can be seen 
 and to restrict oneself to classifying the pathological condition as 
 it exists, instead of venturing into the ever-fluctuating domain of 
 general pathology. 
 
 The apparently extremely variable morphology of skin diseases 
 can thus be brought down to various forms of eruptive lesions on the 
 one hand and of pathological conditions of the skin on the other. 
 I have combined them all under the name of elementary dermato- 
 logical forms. For the description of dermatoses on the bases of 
 their morphology, my work thus becomes reduced to the following: 
 
 Selection of a certain number of elementary forms, easily dis- 
 tinguished or recognized after very little study; description of these 
 forms as accurately as possible, indicating the special anatomical 
 lesions from which they result. 
 
 Next, in view of the fact that these dermatological forms may be 
 encountered in various cutaneous affections, it still remains to take 
 up these affections one by one and to show what constitutes their 
 individuality and on what their diagnosis is based. 
 
 The dermatological types and cutaneous affections which can be 
 approximated on the basis of their morphology are certainly not 
 pathological varieties or diseases in the nosographic sense of the 
 word, but are simple syndromes. Now these syndromes are of two 
 different kinds. Some have an unknown or complex etiology 
 (example: psoriasis); when they have been described with all their 
 features, there is nothing more to be said. Others on the contrary 
 are referable to a known specific cause (example: psoriatiform 
 syphilides) and constitute one of the possible manifestations of a 
 definite disease. The latter will have to be referred to again in 
 the second part of this book and given their proper place under the 
 general description of this disease. 
 
 The first twenty-two chapters are accordingly dedicated to the 
 principal elementary dermatological forms and to the syndromes 
 derived from them. 
 
 A classification of cutaneous diseases on the basis of their mor- 
 phology presents this great advantage that the question of the 
 diagnosis is presented under the same form in which it is met in 
 dermatological practice. On the other hand, it is open to two 
 principal objections. The first is this, that an attempt to take 
 into account all the eruptive forms to which the same disease can 
 give rise, would necessarily involve the splitting of its description 
 into very many fragments. In order to avoid this difficulty, I 
 have restricted myself in the first part to dwelling upon the most 
 common and most characteristic syndromes; the others are briefly 
 
20 DISEASES OF THE SKIN 
 
 mentioned so as to warn the reader against a possible mistake; 
 their description will follow in the second part of this book. 
 
 The other objection is that an arrangement based simply on 
 clinical appearances can in no way constitute a classification. It 
 lot- not claim to do so. Nobody would think nowadays of renew- 
 ing the attempts of Plenke and Willan. It is generally conceded 
 that the only logical and scientific classification in dermatology as 
 well as in other branches of pathology is that which is based on 
 etiology. 
 
 NOSOGRAPHY OF THE DERMATOSES. 
 
 In the second part (Chapters XXIII to XXXI) the point of view 
 is entirely different. There I review the diseases of the skin itself, 
 the pathological entities with a definite etiology, classified according 
 to the nature of their cause. Hence there will be found: artificial 
 dermatoses, 'parasitic dermatoses, infections dermatoses, etc. 
 
 I have put into this class a group of skin diseases united, if not 
 by a first common cause, at least by an identical phenomenon of 
 ;i general nature, namely, essential pruritus, dependent upon a 
 nervous disturbance; this appears to be the second cause of the 
 cutaneous manifestations. This group can be designated under the 
 name of pruritus or neurodermatoses. 
 
 I finally group among the pathological entities the tumors of the 
 shin; admitting that in doing so I conform with custom rather than 
 follow a personal conviction. The etiology of the majority of 
 tumors is unknown or theoretical; it is for this reason no less than 
 on account of their morphology and course that they have hitherto 
 been considered as forming a natural group. 
 
 The etiological classification of skin diseases is confronted with 
 an insuperable difficulty. There exists a series of eruptions, by no 
 means very rare or imperfectly characterized (for example, eczema, 
 lichen, psoriasis) the etiology and pathogenesis of which are entirely 
 unknown. The question arises what place should be assigned to 
 these eruptions. The plan which I have adopted enables me to 
 omit gratuitous hypotheses and avoid forced analogies. These 
 eruptions, the causes of which are multiple, complex or unknown, 
 ;ire not diseases but pure syndromes. Their morphology is practi- 
 cally all that is known about them. They have been described in 
 the first part and do not require to be mentioned in the second. 
 
 THERAPEUTIC NOTES. 
 
 Although I have carefully indicated the attitude to be maintained 
 by the practitioner in connection with each dermatosis, 1 have 
 deemed it advisable to add a brief therapeutic review to this book. 
 
INTRODUCTION 21 
 
 It contains the essential data required for dermatological treatment 
 and the not very numerous prescriptions which it is indispensable 
 to know. It frequently happens that these prescriptions are 
 applicable to several classes of cutaneous affections; by uniting 
 them at the end of the volume, I have avoided frequent repetitions. 
 
 Imperfect as it is, this little book is the fruit of long experience. 
 I have practised and taught dermatology for more than thirty 
 years. The plan was conceived and the text frequently revised in 
 the hospital. By this statement I do not mean to claim that all 
 its contents are entirely original. In the expression of an opinion 
 or in the rendering of a description, it is impossible, at least for me, 
 to separate what is personal from what I have learned from teachers, 
 from the literature and from associates. 
 
 A book of this kind does not aim at replacing the classical treatises, 
 but it is meant to serve as an introduction to and a summary of these 
 larger works. 
 
 J. Darier. 
 
PART I. 
 MORPHOLOGY OF THE DERMATOSES. 
 
 CHAPTER I. 
 ERYTHEMA AND THE ERYTHEMATA. 
 
 Erythema is a congestive redness of the skin, circumscribed or 
 more or less diffuse, usually temporary, which disappears momen- 
 tarily under pressure of the finger. Redness of the skin which does 
 not comply with this definition, such as the following, is not desig- 
 nated as erythema: 
 
 Red spots resulting from the deposit of a coloring matter and dis- 
 appearing on ablution. Peristent red spots of congenital origin, 
 due to increase in size and number of the bloodvessels, but not to 
 congestion; these are vascular nevi (p. 693). 
 
 Red spots which do not disappear under pressure of the finger; 
 these are cutaneous hemorrhages (III). 
 
 Erythemas which are at the same time very extensive or general- 
 ized and very persistent, are commonly designated by the name of 
 erythroderma (VI). 
 
 The term macules is reserved for erythematous and pigmentary 
 but not cicatricial spots following on cutaneous lesions or eruptions 
 of any kind (p. 322). 
 
 Erythema is the first and most common skin reaction produced 
 by an external or internal irritant. 
 
 All acute eruptions and the great majority of chronic skin lesions 
 are accompanied by reddening; this associated erythema is such an 
 ordinary phenomenon that it only exceptionally requires to be 
 taken into consideration. 
 
 Simple, more or less irregular erythema constitutes the eruptive 
 feature of a large complex group of dermatoses known as the 
 Erythemata. The majority of these affections are so imperfectly 
 characterized, however, that it is usually not an easy matter to 
 determine whether a given erythema is a symptom or a disease, 
 
24 ERYTHEMA AND THE ERYTHEMATA 
 
 making it impossible t<> describe these conditions separately. The 
 following, therefore, applies indiscriminately to erythema and to 
 the Erythemata. 
 
 Varieties.— I >e] lending on the apparent pathogenesis of the cuta- 
 neous congestion, it is customary to distinguish between active or 
 arterial erythema, due to an increased blood supply, and passive or 
 venous erythema, due to stasis. 
 
 Ad I re erythema, resulting from a congestive or acute inflammatory 
 hyperemia, is characterized by a bright pink color and a rise of local 
 temperature. It is often accompanied by a sensation of heat or by 
 itching. As a rule, it is ephemeral, lasting only a very few days. 
 
 Passive erythema, on the contrary, produced by stagnation of the 
 blood in the small cutaneous veins and capillaries, is of a darker or 
 purplish-red color, the local temperature is diminished; it sometimes 
 gives rise to a sensation of stiffness, with or without itching, and is 
 generally more or less persistent. 
 
 In a large number of cases, it is impossible to decide if an eryth- 
 ema is active or passive. On the other hand, it is much easier to 
 distinguish varieties, on the basis of whether the erythema is 
 deformed; or from the configuration and duration of the eruption. 
 
 An erythema is described as simple when the erythematous con- 
 gestion is pure, that is, when the change of color of the skin is not 
 complicated by any changes of its thickness, consistence and epi- 
 dermic surface. Otherwise, the erythema is deformed. As a matter 
 of fact, it frequently happens that the exaggerated hyperemia leads 
 to secondary accessory lesions, which more or less modify the char- 
 acters of the eruption; these must be interpreted as irregularities 
 of the eruptive type. 
 
 Erythematous congestion may thus become associated with: 
 intradermic edema (urticarial erythema); cellular infiltration, 
 manifested by a hard superficial elevation {papular erythema) or 
 by deep-seated nodules (nodular erythema)', interstitial hemorrhage 
 {purpuric erythema); early or delayed pigmentation (pigmented 
 erythema ) ; raising of the epidermis in vesicles or bullae (vesicular and 
 bullous erythema); finally furfuraceous or lamellar desquamation 
 (squamous or desquamative erythema). 
 
 These irregularities may be sufficiently marked to constitute 
 intermediary or true transition forms, connecting the erythema 
 with urticaria (II), papules (VII), nodosities (XIV), purpura (III), 
 the dyschromias ( XVI ), bullous dermatoses (X), and erythrodermas 
 (VI). Sometimes, real diagnostic as well as nosographic difficulties 
 arise. 
 
 When in doubt as to the classification of an eruption, either 
 among the erythemata or among the dermatoses of another group, 
 it is advisable to base one's judgment not exclusively on the objective 
 
THE ERYTHEMATA 25 
 
 examination of a given eruptive feature, but on the eruption as a 
 whole, its development and the nature of the underlying process. 
 This rule, although excellent in certain cases, does not suffice in 
 others; the following examples are illustrative. 
 
 In the affection described by Bazin under the name erythema 
 induratum of young girls, histology has shown the tissue-induration 
 to be due to a tuberculoid infiltration. The nature of the patho- 
 logical process here proves the condition to be not an erythema, 
 but a hypodermic nodosity belonging to the tuberculides. The 
 erythematous bullous eruption known as hydroa sometimes appears 
 as an irregularity or a variety of polymorphous erythema, or again 
 seems to be closely related to certain forms of bullous dermatosis. 
 It is therefore differently classified by different authors. 
 
 The configuration and extent of the erythema permit a distinction 
 between the following types: 
 
 Scarlatiniform or Scarlatinoid Erythema. — This is characterized 
 by a more or less general, bright and uniform redness. The red color 
 may result from confluence of miliary or lenticular hyperemic 
 spots, or it may be diffuse from the start. The eruption is ephemeral 
 or more or less prolonged; it is often of medicinal origin (mercury, 
 quinin, opium, etc.), or due to infection (rash preceding smallpox 
 or occurring in the course of gonorrhea, diphtheria, puerperal [and 
 other streptococcic] fevers, indefinite infections) . There exists a rela- 
 tively durable form, with general symptoms, recurrent desquamative 
 scarlatiniform erythema, which connects this type of erythema with 
 the primary erythrodermias. 
 
 Rubeoliform Erythema. — This is made up of small, occasionally 
 confluent spots, with ragged or diffuse margins, rarely slightly 
 elevated; desquamation is absent or insignificant. The eruption is 
 discrete, regional or generalized and of variable duration. The term 
 roseola is employed for nummular or lenticular spots. Four groups of 
 roseola are differentiated: 
 
 (1) Roseolar exanthematic fevers (rubella, rubeola, seasonal roseola) ; 
 (2) Symptomatic infectious roseola (syphilitic roseola, typhoid roseola 
 or lenticular rose-spots, roseola of typhus, rash preceding small- 
 pox, eruptions of cholera, cerebrospinal meningitis, certain septi- 
 cemias) ; (3) Medicinal roseolas (Copaiva balsam, santol oil, turpen- 
 tine, among the so-called balsam roseolas; the roseolas of quinin, 
 antipyrin, odine, etc.); (4) Emotional roseola, which is not a true 
 skin affection, but a physiological phenomenon. It consists of a 
 transitory redness, arranged in spots or as a network, appearing 
 over the chest, neck and shoulders of certain individuals on exposure 
 of the person and identical with the emotional redness of the face. 
 
 Erythema in Patches and Figured Erythema. — These consist of 
 congestive spots, patches or surfaces of irregular shape, discoidal or 
 
2G ERYTHEMA AND THE ERYTI1EMATA 
 
 of variable configuration (erythema marginatum or annulare, etc.). 
 Although sometimes infectious, this type of erythema is more 
 frequently of medicinal, serotherapeutic or autotoxic origin. 
 
 The duration of an erythema, especially the active variety, is very 
 short; as a rule, from one to four days at most. Some last much 
 longer, however, for example syphilitic roseola. In certain forms, 
 there is a marked tendency to recurrences. 
 
 Congestive spots persisting for several months are sometimes 
 designated as erythema perstans, but do not represent a definite 
 pathological type. The presence of a manifestation of this kind 
 should suggest conditions such as tertiary syphilitic erythema, 
 lupus erythematodes, parapsoriasis, tuberculides, the spots of 
 macular leprosy, premycotic erythema, and so forth. Under the 
 name of centrifugal annular erythema, 1 have recently described an 
 eruption which develops acutely, but nevertheless persists for many 
 month- on account of the constant renewal of fresh lesions. The 
 primary urticarial spots become rapidly transformed into rings, 
 prominent and solid to the touch like cords; their peripheral exten- 
 sion, which may amount to several millimeters daily and the frag- 
 mentation of the rings, give rise to arches or strands whose design 
 remains lightly pigmented. This form of erythema is peculiar and 
 very rare; in the reported cases, it was situated on the buttocks, 
 the back, and the thighs. 
 
 Pathological Anatomy. — The clinical appearance of erythema, its 
 configuration and the irregularities to which the eruptive element 
 is subject, are explained to a certain extent by the pathological 
 anatomy. The only essential lesion is the dilatation of the blood- 
 i ssels of the cutis, more particularly those of the papillary body. 
 It disappears in the cadaver and is usually no longer recognizable 
 in cross-sections of microscopical specimens. 
 
 The common rounded or oval configuration of the spots of active 
 erythema is accounted for by the anatomical arrangement, this 
 form being precisely that of the vascular territories of the skin 
 supplied by the same afferent arteriole. Between these territories 
 of direct supply, there exists an anastomotic plexus where the 
 circulation of the blood is normally less active and where the blood 
 has ;i tendency to accumulate in erythema due to stasis (livedo 
 annularis). 
 
 Intense congestion may give rise to exudation of blood plasma 
 from the vessels (urticarial erythema) and to diapedesis of white 
 corpuscles mixed with a few red blood cells. These elements are 
 deposited as cuffs around the vascular branches, the inflammatory 
 increase of the fixed cells contributing to the production of indura- 
 tion and elevation (papular erythema I. 
 
 The anatomical explanation of the pigmentation, phlyctenization 
 
THE ERYTHEMATA 27 
 
 and desquamation, which are the possible results of erythema, will 
 be found elsewhere. 
 
 Etiology. — The causes capable of producing erythema are 
 extremely numerous and varied. An attempt has been made, 
 rationally enough, to group erythema on the basis of its etiology, 
 but this leads merely to an incomplete and artificial classification, 
 the condition representing as it does, not a disease, but purely a 
 symptom. One identical cause may give rise to erythema of a 
 variable objective appearance and course; on the other hand, the 
 same form of eruption may depend on several different causes 
 acting separately or together. In a number of cases, a factor of 
 primary importance, known as predisposition is involved. 
 
 The actual or immediate causes of erythema are either external 
 or internal. 
 
 External Causes. — Erythema from direct provocation; any slight 
 traumatism causing local hyperemia. The passage of the nail over 
 the skin causes the transitory appearance of a red line ; an exagger- 
 ation of this phenomenon acquires a positive diagnostic value in 
 certain cases {vasomotor or meningitic streak). Intertrigo-erythema 
 is in part of mechanical origin. The effects of repeated friction will 
 be pointed out under the heading of the artificial dermatitides 
 (XXIII). Caloric and medicinal external erythema is discussed 
 in the same chapter. Erythema a frigore and active erythema will 
 be referred to presently. 
 
 Bites or stings of the epizoa, lice, bugs, etc., of various insects, 
 such as bees, wasps, hornets, mosquitoes and contact with the 
 hairs of certain caterpillars or some plants, also give rise either to 
 erythema or urticaria, of variable severity and extent in different 
 individuals, or to a true inflammatory dermatitis. 
 
 Internal Causes. — Erythema may make its appearance following 
 the ingestion of certain foods or medicinal agents: the pathogenetic 
 erythema of Bazin; or in the course of various infections, specific or 
 ordinary: infectious erythema; or finally, under the influence of indi- 
 vidual conditions of a nervous, autotoxic, dyscratic or unknown kind, 
 constituting a predisposition or idiosyncrasy. 
 
 Erythema of alimentary origin may be transitory and diffuse, 
 occupying especially the face and the upper part of the trunk, or 
 it may be more lasting. It assumes an urticarial or papular form, 
 or that of a roseola or of marginate patches. All those food sub- 
 stances which are usually prohibited in urticaria and eczema, have 
 been held responsible; although some of these really possess a certain 
 degree of toxicity, the majority act undoubtedly only with the assist- 
 ance of indigestion, habitual dyspepsia, or rather that of a predis-. 
 position which is now apt to be referred to anaphylaxis (pp. 460, 477) . 
 
 Medicinal and serotherapeutic erythema belong under the heading 
 of the toxidermas (XXIII). 
 
28 ERYTHEMA AND THE ERYTHEMATA 
 
 Autotoxic erythema is the designation of conditions developing 
 in uremia, gout, diabetes and hepatic diseases or in the course of 
 acute or chronic appendicitis, obstinate constipation, etc. Such 
 cases are referred to the production of autogenous poisons and in- 
 sufficiency of the renal, hepatic, intestinal emunctories, etc. A 
 popular belief to the effect that the skin under these conditions is 
 damaged on account of the vicarious role it is made to play in sub- 
 stitutiog the organs intended for the normal purification of the 
 organism, is shared by a number of physicians, on what grounds I 
 do not know. This idea is purely theoretical and rests on no reliable 
 basis. 
 
 Infectious erythema is observed in a large number of diseases, being 
 due either to the specific microbe or to a secondary microbic associa- 
 tion. As a rule, it is toxic infectious, the parasite acting apparently 
 through the intermediation of its toxins or the resulting changes in 
 the composition of the blood. Aside from the infections mentioned 
 above, when speaking of roseola, mention must be made of the follow- 
 ing, as capable of giving rise to erythema: Puerperal infection, ulcer- 
 ative endocarditis, pneumonia, diphtheria, the anginas, vaccinia, 
 gonorrhea, furunculosis, the pyodermatitides in general, etc. 
 
 The possibility that a nervous influence by itself alone may give 
 rise to erythema is demonstrated by emotional erythema, usually 
 very transitory, produced by emotions such as shame, anger, joy, 
 etc., on the face, the ears, the neck and sometimes the upper part 
 of the chest (erythema a pudore). Abnormal psychic or nervous 
 conditions, such as are met with at the time of the menopause, in 
 exophthalmic goitre, etc., exaggerate this tendency to blushing, 
 which in some patients is almost a real infirmity. 
 
 The existence of reflex erythema of gastro-intestinal, urethral, 
 uterine origin, etc., has also been admitted and it is naturally diffi- 
 cult in such cases to distinguish between the role of the intoxication 
 ;iml t lie infection. 
 
 Pathogenesis.- The pathogenetic mechanism is certainly not 
 uniform in the group of erythema. Physiology teaches that hyper- 
 emia is subject to vasoconstrictor and vasodilator mechanisms 
 located in the bulbo-medullary center and at the periphery. These 
 may become Involved in a very variable manner; by a local poison, in 
 the case of a flea-bite; by a psychic disturbance in emotional eryth- 
 ema. 1 difficulties arise in such common cases as when an individual 
 is attacked by erythema, for instance, after eating mussels; the ques- 
 tion is whether to interpret the erythema as directly toxic, auto- 
 toxic through indigestion or of reflex nervous origin. Physicians 
 used to hesitate between these theories and with good reason, for 
 they are probably all wrong. In a patient in my service, who 
 was attacked by urticaria under these conditions, the existence of 
 
THE ERYTHEMATA 29 
 
 anaphylaxis was demonstrated by Ch. Flandin and Tzanck. At 
 any rate, it is well to keep in mind that a series of experimental 
 investigations, in harmony with the findings of pathological histology 
 seem to prove that in the great majority of erythemas, those at least 
 which are not absolutely transitory, the process involved is a local 
 inflammation and not simply an angioneurosis, as had been assumed. 
 
 In some instances of infectious erythema, the actual presence of 
 microbes has been recognized in the skin. This is the case in the 
 rose spots of typhoid fever, some forms of gonorrheal and pyococcal 
 erythema and syphilitic roseola. When no microbes are found, it 
 may be assumed that they have already disappeared. But it is 
 extremely probable that in numerous cases the microorganisms 
 act merely indirectly. 
 
 Recently acquired knowledge of serotherapeidic erythema sheds 
 some light on the pathogenesis of erythema in general. I shall have 
 occasion, further on, to point out that the complication of serum- 
 treatment must be interpreted as manifestations of anaphylaxis. It 
 is probably not the anaphylactic poison itself, the apotoxine of Ch. 
 Richet, which acts in the serum-eruptions. There is good reason 
 to believe that changes in the composition of the blood are respon- 
 sible, perhaps the presence of precipitins, as assumed by Hamburger 
 and Moro, Marfan and Rovere, or perhaps other antibodies or 
 derived substances of local origin, or disseminated by embolism. 
 
 What is true for the serum eruptions is equally applicable perhaps 
 to toxinic erythema and infectious erythema. We know that the 
 injection of Koch's tuberculin into tuberculous subjects invariably 
 produces a local erythematous patch, sometimes of erysipeloid 
 type; in some cases it causes, moreover, the appearance of a general- 
 ized eruption of more or less urticarial erythema. It is probable that 
 in the last named cases the composition of the blood is different. 
 
 In children suffering from severe diphtheria and treated with 
 serum, there occurs not only an attack of urticaria or marginate 
 erythema, but scarlatiniform and morbilliform erythema is likewise 
 observed and the question arises if these eruptions are referable to 
 the serum or are of infectious origin. 
 
 The subject is complicated and not yet settled. What seems to 
 be established is that in the pathogenesis of many forms of erythema, 
 just as is true for certain urticarias, purpuras, etc., there is reason 
 to admit the intermediation, between the pathogenic agent (foreign 
 serum, microbe, toxine) and the eruption, of some change in the 
 humoral composition of the blood. 
 
 The ancient formulas in regard to the pathogenic factors of eryth- 
 ema are thus peculiarly vindicated. I was right in asserting that . 
 "while certain agents more or less readily produce eruptions in all 
 persons, others necessarily require a predisposition and active co- 
 
30 ERYTHEMA AXD THE ERYTHEMATA 
 
 operation of the organism/' E. Besnier correctly taught that "the 
 apparent cause of the eruption sometimes seems to determine neither 
 its form nor its course;" and that "the ordinary causes merely 
 bring out the morbid tendency." It is thus understood why Brocq 
 refused to group erythema among the true morbid entities, but made 
 it one of the chief types of his "cutaneous reactions." Recent 
 investigations serve to confirm these clinical observations. 
 
 Prom all that has been said so far, it results that the few dermatoses 
 of erythematous type, to be presently described, cannot be referred 
 to a definite etiology and pathogenesis. It would be a much too 
 simple as well as an erroneous conception of the subject to assume 
 outright that intertrigo is an erythema of mechanical origin; that 
 ■sun hum, frost-bite, and livedo are dependent on a physical cause; 
 that rosacea results from an auto-intoxication; or that erythema 
 multiforme is infectious. These are not morbid entities, but simple 
 syndromes. 
 
 Syphilitic roseola is the only example I shall quote of an erythema 
 having a definite cause, the eruptive manifestation of an actual 
 disease. 
 
 INTERTRIGO. 
 
 The congestive redness which seems to result from mutual friction 
 of two contiguous surfaces, is designated as intertrigo. This term 
 should preferably be employed only as an adjective, attaching it 
 to the name of the dermatosis produced by these conditions. As a 
 matter of fact, aside from intertrigo-erythema, there exists intertrigo- 
 eczema, etc. 
 
 Intertrigo-erythema is ordinarily observed especially in obese 
 individuals, in the fold between the buttocks and on the internal 
 surface of the thighs, for example after a lengthy march. In stout 
 women, it is also seen under the breasts, in the hypogastric fold, 
 in the groin and axillary regions, or in newborn infants, on the 
 buttocks, the folds of the neck, etc. 
 
 Tlie more or less vivid redness is bounded by irregular or diffuse 
 margins; there is local heat or pruritus; pigmentation and sometimes 
 licheni/.ation finally develop. To the mechanical causes arc added 
 the harmful effects of sweating, maceration, regional secretions, 
 secondary fermentations and infections; so that the erythema is 
 frequently complicated by dermatitis, lymphangitis, pyodermatitis, 
 eczematous changes, etc., which may spread. 
 
 The inguinal intertrigo of adults is distinguished from erythrasma 
 (p. 532) and from the eczema marginatum of Hebra (p. 524) by its 
 always symmetrically affecting the two sides of the fold, which is 
 often fissured; and especially by the lesions of intertrigo being 
 
INTERTRIGO 
 
 31 
 
 neither uniform, nor polycyclic, nor marginate, having on the con- 
 trary more or less diffuse borders. 
 
 Infantile gluteal erythema is related to intertrigo and radiates 
 from the intergluteal fold to the thighs, the back, the abdomen, 
 even as far as the heels. It is extremely common and due not so 
 much to friction as to contact of the skin with the dejecta, especially 
 in the presence of diarrhea or athrepsia. Sometimes, the condition 
 is a simple hyperemia, often of a coppery red color, covering a large 
 area, or in patches; in other cases, the erythema is complicated by 
 fissures or vesicles and oozing erosions, briefly by true eczematous 
 changes (intertrigo eczema of the newborn) as shown by Marcel 
 Ferrand; or again, it becomes covered by ulcerations and pyodermal 
 lesions. 
 
 Fig. 1. — Syphiloid (non-syphilitic) dermatitis of the buttocks in the newborn. 
 
 In a form described under the name of 'payulo-lenticular erythema 
 or yosterosive syphiloid by Sivestre and Jacquet, the erosions appear 
 as raised, moist papules. 
 
 Several varieties of these eruptions very closely simulate the 
 polymorphous syphilides of the newborn, as may be seen from the 
 illustration (Fig. 1) and the description of the latter. The diagnosis, 
 in doubtful cases, rests on the general examination of the child and 
 its environment, the direct discovery of the spirochete in the lesions, 
 the Wassermann reaction of the little patient and its mother and 
 finally on the course. As long as any doubt remains all precautionary 
 measures must be taken to guard against contagion. 
 
 The treatment of intertrigo consists in the frequent application 
 of astringent or weakly antiseptic soothing lotions. An essential 
 precaution is the successful separation of the affected surfaces, by 
 
32 ERYTHEMA AND THE ERYTHEMATA 
 
 means of sterilized gauze, or especially by neutral mineral powders. 
 Zinc oxide pastes are also appropriate, but salves are often injurious. 
 The diet of children must be closely watched, and, if necessary, 
 corrected. 
 
 ERYTHEMA SOLARE SEU ACTINICUM. 
 
 The inflammatory redness which follows after exposure to the 
 rays of the snn is known as .sunburn. At the end of a few hours, 
 the exposed surfaces, usually the face, especially the nose and ears 
 and the hands, present an intense congestion, with swelling, burning 
 and itching; this lasts a few days, then the epidermis desquamates 
 in Large shreds and only a slight pigmentation is left behind. Not 
 all individuals exposed to light radiations are affected to the same 
 degree. Delicate skins, blondes, certain neuropaths and persons 
 not accustomed to the open air, are more susceptible to sunburn, 
 especially in the spring near the water, or in excursions on glaciers. 
 
 Insulation, or heat-stroke, is an altogether different accident, 
 sometimes very grave, characterized by general phenomena instead 
 of cutaneous lesions and referable to a different pathogenesis. 
 
 Solar erythema differs also from burns. It has been more than 
 sufficiently demonstrated that it is not the caloric rays, but the 
 chemical rays of the spectrum, the violet and ultraviolet rays which 
 are responsible in these cases. The electric arc-light is accordingly 
 capable of producing an entirely similar electric erythema. The same 
 chemical radiations are utilized in phototherapy, for example in 
 Finsen's method. 
 
 A few very simple precautions, such as wearing a veil, the appli- 
 cation of creams, lotions, or powders made with quinin or esculine, 
 suffice to protect against sunburn. The treatment is that of an 
 artificial dermatitis or a burn of the first degree. Numerous 
 observers believe, not without good reason, that the action of the 
 solar rays plays a part in the production of pellagrous erythema. 
 
 Pellagra is a non-contagious general disease, endemic in many 
 countries, notably in Italy (mal della rosa), where for a long time 
 it has constituted a veritable scourge; in the Balkan provinces, in 
 Spain, in southwestern France, in Egypt and in Asia minor. In the 
 last ten years, important foci have been discovered in the United 
 States, Guyana, the Antilles, and a few cases in Great Britain. 
 
 Pellagra usually starts in the spring, followed by seasonal out- 
 breaks. The erythema which often betrays its presence, manifests 
 itself on the exposed parts, especially on the back of the hands and 
 the wrists, sometimes on the face, neck, upper part of the trunk, and 
 even on the dorsal aspect of the feet. It consists of a sombre redden- 
 ing, with more or less clearly marked outlines, sometimes com- 
 plicated by small bloody suffusions, fissures, or bullae. [The sharp 
 
ERYTHEMA SOL ARE SEU ACTINICUM 
 
 :;:; 
 
 line of demarkation between the affected areas and the normal skin 
 is very characteristic of pellagrous erythema.] At the end of two 
 or three weeks the skin becomes pigmented, darkens, and is shed in 
 large shreds, finally undergoing atrophy, so as to resemble the skin 
 in certain senile cachexias. Lesions of the mucous membranes are 
 not infrequently observed, for example a bullous and later on 
 diphtheroid stomatitis, as well as an analogous vulvitis. 
 
 Aside from the cutaneous symptoms, a very marked loss of 
 strength is noted after the onset of the disease, followed by a true 
 asthenia, with serious digestive disturbances, anorexia, fetid diar- 
 rhea, emaciation, sometimes chills and fever, ordinarily serious 
 
 W- J$££;~ 
 
 m J .^H 
 
 
 J / M 
 
 "**" 'S^lfcf m 
 
 m "m 
 
 ^ 
 
 <--— 
 
 -*8L \ 
 
 • 
 
 Fig. 2.— Pellagra. Si 
 
 r, Garrison and MacNeal, Thompson-McFadden Pellagra 
 Commission. 
 
 mental and nervous disturbances, paresthesias, hyperesthesias, 
 convulsions, melancholia and delirium with a tendency to suicide. 
 Many patients drift into insane asylums. The mortality in certam 
 foci is appalling, but there are numerous abortive cases which may 
 remain unrecognized. 
 
 The theory according to which pellagra is due to a chronic intoxi- 
 cation by spoiled maize (Zeism) has been widely accepted. It is 
 claimed, however, that pellagra appears also in regions where maize 
 (Indian corn) is never used. The infectious theory, which is now 
 opposed to the maize theory, acquires much probability from recent 
 epidemiological investigations, notably those of L. W. Sambon: 
 Simulides or other insects are assumed to act as carriers of a special 
 3 
 
34 ERYTHEMA AND THE ERYTHEMATA 
 
 protozoan parasite, supposed to be the causative agent of pellagra. 
 There would thus be a remarkable parallelism between this disease 
 and malaria. [The etiology of pellagra is not clear but the weight of 
 evidence at present would indicate that the disease is one of mal- 
 nutrition due to a defective diet. The parallelism is rather with beri- 
 beri than malaria. 1 1 >oubt prevails as to the nature of an absolutely 
 identical or sometimes attenuated syndrome which may be observed 
 in European countries among cachectic individuals, inebriates, 
 or in those in a state of physical and moral deterioration. Some 
 interpret this syndrome as a pellagroid erythema of alimentary or 
 cachectic origin, whereas others admit no essential difference between 
 this pellagroid and true pellagra. The point has not yet been settled. 
 
 ERYTHEMA PERNIO OR FROST-BITE. 
 
 Everybody knows frost-bite, in the form of a purplish and painful 
 reddening frequently observed during the cold season, especially 
 
 in children and youthful individuals. In order of frequency, these 
 lesions affect the hands, notably the ulnar border and the fingers, the 
 toes and heels, the ears, the nose and more rarely the cheeks. 
 
 In thejirsf degree they consist of a swelling of the skin, which is of 
 a dark or bluish-red color, tense, glazed, indurated and cold to the 
 touch. Although the erythema is evidently due to stagnation, 
 there occurs an instantaneous active hyperemia when the parts are 
 too rapidly heated, the sensation of stiffness changing into an itching 
 and very painful burning sensation. 
 
 The erythema may be limited to patches, or diffusely outlined or 
 even generalized over nearly the entire region. 
 
 In the second degree, the frost-bite is "open," as it is ordinarily 
 described. The ulcerations result either from cracks which appear 
 in the folds, or from sometimes rather large bullae which originate 
 on the swollen surfaces, probably under the influence of infection by 
 pus-cocci. A persistent exudation follows, or a suppuration with 
 crusts, which may lead to spongy bleeding ulcers, causing an actual 
 lo>> of substance. Under these conditions, manual labor or walking 
 sometimes become impossible. 
 
 Untreated frost-bites usually last with exacerbations through the 
 entile winter and disappear in the spring; but there are exceptional 
 cases which persist even in the summer. 
 
 The part played by the season and the local action of the cold are 
 beyond dispute. However, the determining causes must not be 
 allowed in overshadow the predominating importance of the soil. 
 The age of five to fifteen years predisposes to frost-bite; but not all 
 children are attacked, and moreover, cases are observed in young 
 and adult individuals. Anemia, the so-called lymphatic constitu- 
 
ERYTHEMA PERNIO OR FROST-BITE 35 
 
 tion and arterial hypotension, are evidently very often involved; 
 it may even be stated that the frequently observed association of 
 frost-bite with habitual acro-asphyxia, with adenopathies, with the 
 scrofulous diathesis, might cause them to be classified among the 
 manifestations of attenuated tuberculosis which are now designated 
 as tuberculides (p. 563). This view is supported by the not uncom- 
 mon cases where the frost-bite is apparently transformed into 
 erythematous lupus, the chilblain lupus of Hutchinson; indicating a 
 probable relationship between these two affections, the second of 
 which is considered as a tuberculide (p. 571). The cases in which 
 chilblains give rise to angiokeratoma, or alternate with papulo- 
 neurotic tuberculide, point in the same direction. 
 
 * Treatment. — In frost-bite of the first degree, the patient's suffer- 
 ings are greatly relieved by means of lotions made with lukewarm 
 or warm water, followed by rubbing with camphorated spirits, 
 alcohol with a little iodin, or an infusion of tannic acid. Salves or 
 powders made with tar or ichthyol are sometimes useful. 
 
 In case of cracks or ulcerations, a moist occlusive dressing is 
 applied, or applications of linimentum calcis or vasolanoline, 
 until cicatrization is obtained, before resorting to astringents and 
 keratoplastic agents, such as ichthyol, resorcinol, etc. 
 
 Hydrogen peroxide in local baths of fifteen to twenty minutes, 
 repeated two or three times daily, is often remarkably successful. 
 
 The "biokinetic method" of Jacquet, provided it is properly 
 applied, constitutes a preventive and excellent, treatment of frost- 
 bite and chilblains. The patient must actively move (8 or 10 times 
 daily for five minutes) all the joints of the affected extremities, 
 which meanwhile are kept in an elevated position. 
 
 General medicinal treatment, as employed in the lymphatic and 
 scrofulous diathesis, must not be omitted, in the form of fresh air, 
 dry or alcoholic rubs, cod-liver oil, arsenic, calcium, iodide of iron, 
 etc. Certain forms of opotherapy are sometimes indicated (supra- 
 renal extract, etc.). 
 
 The disease known as trench-foot (said to be frozen feet), and 
 frequently observed in the great war, differs from chilblains in many 
 respects. It occurs in soldiers who have been obliged to stand 
 several days in cold water or mud, even in the absence of ice, and 
 is the result of the enormous withdrawal of heat, together with the 
 effects of the [prolonged erect or] slanting position, the general 
 fatigue and sometimes the constriction of the legs and feet. It 
 consists of a purplish and very painful swelling, which interferes 
 with walking, either without cutaneous lesions or accompanied by 
 purpura, bullae, or even more or less extensive and deep sloughs. 
 In such cases we have noted, with Civatte, a very persistent, pain- 
 ful anesthesia of the distal end of the foot, indicative of peripheral 
 
36 ERYTHEMA AND THE ERYTHEMATA 
 
 neuritis. Vascular lesions are held responsible by others. The 
 duration may be several months, even in cases which receive proper 
 treatment with baths or douches of hot air and kinetotherapy in 
 the elevated position. 
 
 ACRO ASPHYXIA AND LIVEDO. 
 
 Acro-asphyxia and livedo are two other forms of passive erythema 
 which musl be considered in connection with chilblains. 
 
 Arm-asphyxia is a chronic congestion of the extremities, which 
 an- of a purplish red color, habitually cold and often damp and 
 flaccid. The ischemic spot produced by digital pressure requires a 
 long time, sometimes nearly a minute, to resume its red color by the 
 inflow of blood. 
 
 This affection is observed under a variety of conditions. 
 Obviously, this syndrome can be produced by a spasm of the veins, 
 a change of the venous walls or a lowering of the arterial tension 
 (cardiac or pulmonary lesions, cachexia). Permanent nervous dis- 
 turbances, nutritional impairment and chronic exogenous or autog- 
 enous intoxications may undoubtedly lead to the same result. 
 Children or youthful individuals having the scrofulous diathesis 
 are particularly susceptible. The manifestations are accentuated 
 by cold. 
 
 Without itself causing seriotis inconvenience, acro-asphyxia 
 creates a scat of predilection for chilblains, tuberculides, angio- 
 keratoma, artificial dermatitides and pyodermatitides and imposes 
 ;i sluggish, dragging tendency on the course of all these skin lesions. 
 
 Livedo (livedo annularis a frigore or reticular asphyxia) has a 
 practically identical etiology and significance. It is observed 
 especially on the outer aspect of the forearms, arms and thighs, on 
 the Hanks and sometimes over almost the entire integument. 
 
 It consists <•!' a persistent purplish reddening, increased by cold, 
 which appears on the skin as a network made up of strands of 
 variable size, enclosing round or oval meshes. These meshes have a 
 normal color and correspond to the territories of direct blood supply, 
 whereas the strands of the network represent the anastomotic 
 zones between these territories. Livedo accordingly represents the 
 " negative" of a roseolar eruption. 
 
 ROSACEA. 
 
 Rosacea (acne rosacea, acne rosea, gntta rosea, Fr. couperuse) is 
 ;i 3pecial affection of the face, a passive erythema, persistent but 
 variable, sometimes complicated by pustules. Its principal local- 
 ization is the nose, the cheek and the middle of the forehead; by 
 extension, it may reach the chin and the temples. 
 
ROSACEA 37 
 
 Etiology. — Rosacea does not occur in children; it appears either 
 after puberty, or more generally toward the age of forty or fifty 
 years in women at the time of the menopause. It usually disap- 
 pears in old age. 
 
 Many different factors may enter into its etiology. It is very 
 frequently preceded by a stage of acute congestion of the face, 
 recurring in attacks and designated as erythrosis facialis; on the 
 other hand, it almost invariably enters into the symptom-complex 
 of kerosis (p. 196) with or without seborrhea. Both these morbid 
 conditions act as intermediaries between the general disturbances 
 presently to be enumerated and the chronic erythema of the face 
 which we call rosacea. 
 
 Most commonly, digestive disturbances are responsible, such as 
 habitual constipation, gastro-intestinal fermentations, hepatic 
 dyspepsia, abuse of stimulants, etc. Many people, especially young 
 women, are subject to attacks of acute congestion of the face, 
 diffuse or in patches, after eating too rapidly without sufficient 
 chewing ( tachyphagia), or under the influence of certain foods or 
 beverages. This facial erythrosis, which seems to be the effect of a 
 reflex of gastric origin (L. Jacquet) may recur during several years, 
 or it may change rather rapidly into rosacea. In other cases, rosacea 
 is established from the start with persistent red spots which have 
 a tendency to become confluent. This is apt to be the case in 
 inebriates, especially wine-drinkers; the florid complexion and red 
 nose are not a sign of splendid health, but rather an index of 
 gastro-hepatic dyspepsia. 
 
 Disturbances of the genital functions, especially utero-ovarian; 
 the menopause; dysmenorrhea; inflammations of the tubes and 
 ovaries; metritis, etc., likewise predispose to rosacea and especially 
 to its localization on the chin. Chronic cardiac and pulmonary 
 lesions are occasionally responsible. Affections of the nasal fossae 
 and sinuses apparently invite the skin lesion in a number of cases 
 and the same is true for dental caries, which through the loss of 
 many teeth, moreover, becomes an important cause of dyspepsia. 
 
 The action of cold, heat, or wind; the menstrual periods; cutaneous 
 irritations of all kinds, contribute to the renewal of attacks and to 
 the coalescence of the red spots, which become darker, of a purplish 
 or dark blue color, or to the exacerbation of rosacea already estab- 
 lished. 
 
 Symptoms. — In its fully developed stage, rosacea consists of a 
 persistent more or less diffuse redness, without elevation of the local 
 temperature. After a while, superficial telangiectases make their 
 appearance; small undulating veins ramify over the nasogenial 
 grooves, furrow the wings of the nose and twist in intertwining 
 twigs over the nose, the cheeks, the temples, the forehead, and the 
 
38 ERYTHEMA AND THE ERYTHEMATA 
 
 chin. In well-marked cases of kerosis, the skin becomes swollen, 
 thickened as n whole, and a few hypertrophied sebaceous glands 
 may project over the surface. This condition in particular is desig- 
 nated popularly as "gin-blossom." 
 
 Although rosacea may run its course unmixed, it very frequently 
 becomes complicated by folliculitis, especially in patients having 
 seborrhea. The majority of authors have on the other hand inter- 
 preted this acneiform folliculitis as primary and causative of the 
 surface redness. Careful observation of these patients shows this 
 to be incorrect. These follicular inflammations have also been 
 generally confused with the papulopustules of acne vulgaris (p. 385). 
 lima has shown that they differ from the latter by the absence of 
 comedones, by their superficial situation, by their localization and 
 by the age of the patients. 
 
 The follicular inflammations of rosacea appear in attacks affecting 
 from two to ten follicles at once; they pass through all the stages 
 of papules, pustules, crusts, lasting from two to four days and are 
 constantly repeated. Overindulgence in food, however, may give 
 rise to a crop of twenty to thirty inflamed follicles. They aggra- 
 vate the previous condition, unpleasantly affecting the patient's 
 appearance and inevitably leaving at least a minute cicatrix. An 
 extreme degree of rosacea seriously disfigures the sufferer. The 
 purple pimply nose, deformed by swollen ridges separated by deep 
 grooves, traversed by large dilated veins, is increased in size in all 
 directions; this condition has been described as a separate affection 
 under the name of rhinophyma (p. 374J. The other parts of the face 
 are sometimes likewise purplish, swollen and scattered over with pus- 
 tule-, cicatrices and telangiectases. The general impression is far 
 from esthetic. 
 
 Diagnosis. The diagnosis of rosacea is generally easy, except 
 perhaps when it presents certain features suggestive of iodides and 
 bromides, or of lupus pernio, which is by no means limited to the 
 nose, or of lupus erythematodes, which is characterized by the 
 sharp outline of its margins. The differentiation from certain ter- 
 tiary syphilides of the middle of the face may prove extremely 
 difficult. 
 
 Treatment. In the first place, the various etiological factors 
 referred to above must be looked for and appropriate diet and 
 internal treatmenl prescribed. The local treatment varies with the 
 degree of i he affecl ion and the presence or absence of complications. 
 In ,i moderately >v\cw or mild case, the rule is to exhaust the power 
 of topical agents before resorting to the obliteration of the dilated 
 vessels. ( Ointments are often badly tolerated. Sulphur and ichthyol 
 pastes, powders, bathing with lukewarm naphthol or ichthyol soap 
 solution, sprays or warm lotions with astringent fluids with or with- 
 
ERYTHEMA MULTIFORME 39 
 
 out the addition of bichloride are decidedly preferable. A sulphur 
 and camphor lotion may by itself alone lead to considerable improve- 
 ments provided the general indications have been met. Local 
 massage, or better still, frequent sessions of facial gymnastics, advo- 
 cated by L. Jacquet are often very efficient. Finally, when required, 
 the treatment may proceed to obliteration of the telangiectases, 
 preferably with the galvanocautery, or exceptionally by means of 
 electrolysis or scarifications. 
 
 In a grave case of rhinophyma, after relieving the irritation and 
 checking the suppuration by the application of mild antiseptic 
 sprays and dressings, surgical intervention may prove necessary 
 in the form of nasal decortication. 
 
 ERYTHEMA MULTIFORME. 
 
 Under the name of multiform or polymorphous exudative ery- 
 thema, Hebra distinguishes in the heterogeneous group of erythema 
 a syndrome which one is almost tempted to regard as a disease. 
 In its behavior it approaches the eruptive fevers, but as it is 
 neither specific nor contagious, it must be described as pseudo- 
 exanthematic. 
 
 Symptoms. — The eruption, which is often accompanied by sys- 
 temic phenomena, consists either of erythematous papular elements, 
 or of vesicles or bullae, or finally of nodosities. It is somewhat 
 uncommon to see these different forms of elements combined in the 
 same individual. 
 
 The following types may therefore be described : Papido-erythem- 
 atous, which alone will be discussed here; a bullous type or hydroa 
 (p. 175) and the so-called erythema nodosum (p. 265). Polymor- 
 phous erythema of the papulo-erythematous type is characterized 
 by nummular or lenticular congestive spots, the center of which 
 promptly becomes cyanotic; these spots spread, remaining flat or 
 becoming wheal-like or papular, sometimes discoid, or depressed in 
 their center (Fig. 2). The livid color of the spots, their bright-red 
 border, their manner of development and the distribution of the 
 eruption are sufficiently characteristic. The lesions may also be 
 whitish in their middle, appear to be bullous or actually become so 
 in some cases; or again, their center may become purpuric. Their 
 extension is rapid and sometimes gives rise to marginate spots, or 
 even to rings, through the obliteration of the central area (erythema 
 annulare). 
 
 The eruption is composed of a very variable number of elements, 
 disseminated or arranged in groups, sometimes confluent, usually 
 symmetrical. The seat of predilection is the dorsal surface of the 
 wrists, hands and forearms; it sometimes occurs on the fingers, the 
 
40 
 
 ERYTHEMA AND THE ERYTHEMATA 
 
 elbows, the nape of the neck, the forehead, the knees, and rarely 
 the feet. Heat, pruritus and local tension are present, often regional 
 swelling, sometimes arthralgias or even arthritis simulating acute 
 articular rheumatism; prostration, headache, gastric disturbance 
 and some fever at the onset. As a rule the eruption extends by 
 successive attacks. The entire duration is from one to five weeks. 
 Moderate desquamation is noted on its subsidence. 
 
 Relapses are not uncommon; and Brocq finds in these relapses a 
 connecting link between the recurrent cases with grouped lesions 
 accompanied or not by especially painful phenomena and the 
 painful polymorphous dermatitides (p. 179). 
 
 pular type. 
 
 Etiology.- Notwithstanding its appearance of a fairly well 
 defined morbid entity, polymorphous erythema seems due to quite 
 a number of ordinary causes. The effects of cold, alimentary or 
 medicinal intoxications; infections, such as rheumatism, the anginas, 
 gonorrhea, syphilis, tuberculosis, leprosy and perhaps reflex actions 
 or auto-intoxications may all be present, without lending a special 
 feature to the disease. In other words, the true cause is not known. 
 It is probably a reaction of the organism under the influence of 
 various intoxications or toxins. [There is reason to believe that 
 low-grade infections are the most frequent etiological factor.] 
 
 Treatment.- In the first place this must not be irritating. Accord- 
 ing to the cases, purgatives, rest, a light diet may suffice; calcium 
 chloride, aspirin and salicylates are often useful; iodides have been 
 
SYPHILITIC ROSEOLA 41 
 
 highly recommended, but are rather injurious. Locally, applications 
 of neutral powders will suffice, with protective dressings if needed. 
 
 As it has been shown by the work of Prof. Landouzy and his 
 pupils that polymorphous erythema in a considerable number of 
 cases is due to tuberculosis, it is advisable to prescribe an appropriate 
 hygiene for convalescent patients and to keep them under prolonged 
 observation. 
 
 SYPHILITIC ROSEOLA. 
 
 No other infectious erythema possesses the same importance as ( 
 syphilitic roseola; which is accordingly selected for a special descrip- 
 tion. It is the most common of the cutaneous syphilides and con- 
 sists of an eruption of spots, at first of a peach blossom color, of a 
 deeper pink after a few days, of nummular size, rounded or oval 
 shape and indefinite margins; these spots being at no time either 
 squamous or pruritic. This eruption is scattered indiscriminately 
 on the flanks, the chest, the back and the abdomen, sometimes 
 extending to the neck, the limbs as far as the palms and soles, very 
 rarely to the face where it is observed only on the forehead. 
 
 In the absence of early and radical treatment, it usually appears 
 from forty to fifty days after the chancre, beginning on the flanks 
 and hypochondriac regions, developing in a fortnight and lasting 
 from three to six weeks or two months. It occasionally fails to make 
 its appearance even in cases where the chancre has remained 
 unrecognized and no treatment has been instituted. Not infre- 
 quently it escapes the patient's attention and must be looked for. 
 Sometimes it is so profuse and high-colored as to give the skin a 
 mottled appearance. 
 
 The roseolar elements, especially when small, of lenticular dimen- 
 sions, may cause a slight protuberance, as the result of some con- 
 gestive edema; representing urticarial roseola. The form in which 
 the macules develop into papular syphilides is designated as papular 
 roseola. 
 
 There may be a recurrence of the roseola in the course of the first 
 or second year, or even later. These recurrent roseolas are usually 
 rather pale and composed of larger and less numerous spots, which 
 are often circinate or annular; their duration is apt to be prolonged. 
 
 Tertiary roseola, or tertiary erythema, is the name given to dull red. 
 non-squamous and non-infiltrated spots, polycyclic or circinate, 
 occupying the trunk and limbs and very rebellious to treatment. 
 These lesions are met with in long-standing syphilitic cases which 
 have been subjected to energetic and prolonged treatment. They 
 may be interpreted as the attenuated equivalents of tuberculo- 
 ulcerative syphilides. 
 
 Syphilitic roseola differs from the pityriasis rosea of Gibert and 
 
42 ERYTHEMA AND THE ERYTHEMATA 
 
 from eczema by the absence of desquamation of any kind; from the 
 balsamic roseolas, by its less intense color, its slow development and 
 the absence of itching. Among the affections capable of causing real 
 diagnostic difficulties may be mentioned the roseola of leprosy and 
 the roseola of mycosis fungoides, but these are very rare and are accom- 
 panied by other symptoms of these two diseases. Anti pyrin roseola 
 is likewise objectively identical, but is the least common of anti- 
 pyrin eruptions and lasts only eight to ten days. The most ordinary 
 practical difficulty results from the macules sometimes remaining 
 on the skin after a pyodermatitis, scabies, or pediculosis. All doubts 
 will be cleared up by the history and the topographical distribution 
 of tile lesions. 
 
 Diagnosis. — The diagnosis of syphilitic roseola should always be 
 carefully confirmed through the demonstration of other signs of the 
 infection, such as glandular enlargement, mucous patches, remains 
 of the chancre, alopecia, headache, etc., or by means of the ^Yasse^- 
 mann reaction. 
 
 Treatment. — Treatment should be prescribed only when the diag- 
 nosis is positive; specific medication suffices, whereas irritating 
 topical applications, sulphur baths and all methods which congest 
 the skin, usually merely aggravate and prolong the eruption. 
 
CHAPTER II. 
 URTICARIA. 
 
 The name urticaria is applied to an eruption composed of peculiar 
 elements which for lack of a special denomination are described as 
 urticarial patches or papules or wheals. This eruption is essentially 
 pruritic in character. 
 
 The eruptive element of urticaria is an elevated distinctly outlined 
 efflorescence, light pink in color or of an opalescent white with a 
 pinkish areola; of a rounded or oval shape, sometimes polycyclic 
 and of solid consistence. Its dimensions, usually nummular, vary 
 from the size of a lentil to that of a more or less extensive surface. 
 
 The eruption consists of an extremely variable number of elements, 
 appears suddenly, in a few seconds, is transitory or ephemeral, 
 vanishing after a few minutes or hours; the pinkish color fades, the 
 elevation flattens out and, with some exceptions, no trace is left 
 behind. 
 
 The eruptive element is typical, but in spite of the characteristic 
 eruption, urticaria can in no way be regarded as a disease. It is 
 often a simple symptom, a cutaneous reaction which may be provoked 
 by a great variety of causes. It is sometimes a syndrome, when the 
 eruption assumes the behavior of a pseudo-exanthematic eruption 
 and is accompanied by general disturbances; but it is not a disease 
 in itself. 
 
 It cannot be overemphasized that a fundamental characteristic 
 of urticaria is that it is invariably associated with severe itching, 
 heat or formication, so that scratching becomes imperative. The 
 pruritus often precedes the appearance of the efflorescences; it is 
 usually more diffuse than the eruption. 
 
 In an attack of urticaria, the skin of the affected regions presents 
 almost invariably, at any rate temporarily, a congestive tendency 
 which may be designated as urticarism; owing to which new lesions 
 may be provoked by scratching, rubbing, the action of cold or 
 irritation of any kind. Jacquet has shown that no new lesions 
 appear under really occlusive padded dressings. It may accordingly 
 be stated that in urticaria the pruritus is primary as compared to 
 the eruption. Many dermatologists therefore group urticaria under 
 the heading of pruritus. 
 
 The site of urticaria is extremely variable; it is localized or 
 regional or it may be generalized; it affects preferably the trunk and 
 
11 
 
 URTICARIA 
 
 liml >s, but sometimes also the palmar and plantar regions, the face 
 and the hairy scalp. In regions with a loose cellular tissue, such as 
 the eyelids, the prepuce [the lips], etc., the eruption manifests itself 
 in the form of an enormous urticarial edema, with diffuse margins, 
 rather alarming, but transitory. 
 
 
 Fig. 4. — Acute urticarial eruption, on the flank of an adult man (developing in the 
 course of axillary pyodermatitis) . 
 
 The mucous membranes may be invaded, notably the mouth, 
 pharynx, and larynx; redness and edema occur, and the latter may 
 interfere with respiration. Mention has even been made of urti- 
 caria of the nasal fossae, the bronchi and the digestive apparatus. 
 This is imaginary and merely a theoretical explanation of hay-fever, 
 certain forms of asthma and of paroxysmal diarrhea. 
 
 The general phenomena which may accompany the onset of certain 
 very severe attacks of urticaria consist in fever, sometimes high 
 but very transitory {urticarial fever) and prostration, with more or 
 less marked digestive disturbances. 
 
 Varieties. The varieties of urticaria are numerous and are 
 derived from the morphological aspect of the lesions or the course 
 of the eruption. The configuration of the eruptive lesions, discoid, 
 annular, circulate or linear; as well as their porcelain tint, have no 
 special importance. However, the center of the spots may assume 
 ;i purplish line, resisting digital pressure; this is hemorrhagic urticaria, 
 separated merely by a shade from purpura urticans. The bloody 
 infiltration in the skin in these cases undergoes the usual transfor- 
 mation into pigment, so that the elevations leave brownish macules 
 behind; this pigmented urticaria must be carefully distinguished from 
 urticaria pigmentosa (p. 70o). 
 
 The appearance of a small, hard and persistent papule in the center 
 
ETIOLOGY 45 
 
 of the urticarial spots characterizes the papular urticaria of several 
 authors. This is described in this book under the name of strophulus 
 (p. 141). 
 
 In certain very unusual cases, the urticarial elevations become 
 topped by a blister containing a serous and later a purulent fluid 
 which dries in crusts. This bullous urticaria is not readily distin- 
 guished from certain forms of pemphigus (p. 175). [Both papular 
 and bullous urticaria are not uncommon in the urticarias of infants 
 and children.] 
 
 The eruptions which have sometimes been described as urticaria 
 perstans, the lesions of which persist for months or years, and which 
 must not be confused with constantly recurring chronic urticaria, 
 are probably related either to the prurigos (p. 498) or to the pre- 
 mycotic eruptions (p. 657). 
 
 Giant urticaria is a separate clinical form, which will be briefly 
 discussed further on. The same remark applies to factitious urticaria. 
 
 The behavior of urticaria permits the distinction of an accidental 
 form, instantaneously produced by an external irritant; an acute 
 form, in which the eruption consists of a single attack, or a few 
 successive or overlapping attacks, so that the patient is well again 
 in twenty-four hours, in two or three days, or in a week; and a 
 chronic urticaria, in which successive attacks occur continuously, 
 or at intervals, during months or even years. In the last named 
 cases the itching becomes a real torment, disturbing sleep and 
 exhausting the patient, as a result of the incessant scratching, the 
 skin becomes covered with excoriations, crusts, and pigmentations. 
 The condition may terminate, according to the age of the patient, 
 in Hebra's prurigo, or in ordinary diffuse prurigo (pp. 494 and 496). 
 
 Etiology. — The causes of urticaria are in part local, direct or 
 determining; and in part general, indirect or predisposing. They 
 may become associated in variable proportion in producing the 
 eruption. 
 
 It will be readily understood that a very active direct cause may 
 by itself alone give rise to urticarial efflorescences, in all persons 
 indiscriminately; on the other hand, in very strongly predisposed 
 individuals, the most ordinary and trifling irritant may produce the 
 eruption. Between these two extremes all variations are met with. 
 
 Authors who maintain that urticaria should be considered as a 
 disease having a deep-seated cause in the organism, refuse to include 
 with it such artificial efflorescences as that produced, for instance, by 
 the stinging nettle, although the very name of the disease is derived 
 from that plant [urtica]. This conception has certain arguments 
 in its favor, but I cannot accept it for the reason that the eruption is 
 identical in urticaria of external and of internal origin and that it is 
 impossible to draw a sharp line between these two affections. All 
 
46 URTICARIA 
 
 urticarial eruptions are therefore grouped together in this book 
 under the heading of urticaria. 
 
 External Causes. — Stings produced by the glandular hairs of 
 nettles, the stings of mosquitoes, bed-bugs and fleas, contact with the 
 hairs of processional caterpillars, with medusae, or various poisonous 
 plants, give rise after a few seconds to severe pruritus and slight 
 reddening. Next, especially on scratching, or when the congested 
 and sweaty skin is washed with cold water, an eruption of accidental 
 urticaria, or even of acute generalized urticaria in predisposed 
 individuals, occurs. A local cause should therefore be looked for 
 in the first place in cases of urticaria as in any pruritus. 
 
 It is superfluous to enumerate all irritants capable of inducing the 
 eruption in temporarily or permanently susceptible individuals. 
 The slightest friction or contact with water or even air may be 
 sufficient. 
 
 Internal Causes. — Clinical studies of the manifold conditions 
 under which urticaria is observed, has led to the following conclu- 
 sions: The predisposing factor in urticaria was supposed to be 
 referable to somewhat indefinite nervous states, often of congenital 
 origin in children and youthful individuals, of acquired origin in 
 adults, due to mental strain, hysteria, neurasthenia, chronic intoxi- 
 cations, or weakening from any disease. Violent emotions, anger, 
 or fear, may precipitate a crisis. 
 
 Digestive disturbances play the principal part in other cases, 
 especially gastric dyspepsia, dilatation of the stomach, diseases of 
 the liver, habitual constipation. An attack of indigestion, or par- 
 taking of certain foods or drinks, brings on the eruption in some 
 individuals, the following substances appearing particularly injur- 
 ious; Deep-sea fish, crustaceans, shellfish, especially mussels, pork, 
 game, eggs, preserves, cheese, ices, strawberries, raspberries, wines, 
 tea and coffee, many medicinal agents, etc. 
 
 In urticaria ab ingestis, a reflex action of gustatory or gastric 
 origin has sometimes been assumed on account of the very brief 
 period before the onset of the attack. The reflex may perhaps also 
 start from the genito-urinary organs, according to the older views. 
 
 The urticaria from abnormal intestinal fermentations, from renal 
 or hepatic insufficiency, from gout, pregnancy, etc., was interpreted 
 as autotoxic, while the urticarial eruption which sometimes precedes 
 or accompanies the eruptive fevers, intermittent fever, etc., was 
 considered as infectious urticaria. 
 
 It was known finally that several varieties of urticaria may occur 
 in blood diseases, leukemias, etc. 
 
 Jn the last few years, however, the subject has taken on another 
 aspect through laboratory and experimental investigations along 
 the line of anaphylaxis (p. 460), as will be discussed further on. 
 
PATHOGENESIS 47 
 
 The fact has now been established that the majority of urticarias 
 are due to anaphylaxis. 
 
 Pathogenesis. — The eruption of urticaria obviously results from a 
 local congestion of the cutaneous vessels with serous exudation espe- 
 cially in the papillary body, sometimes extending to the hypoderm 
 and more rarely to the epidermis. The firmness of the urticarial 
 wheal, its pallor resulting from the compression of the bloodvessels 
 and the cleavage of the epidermis in the bullous form are proof that 
 the plasma is exuded under high pressure. 
 
 It should be kept in mind that toxic or infectious erythema may 
 be urticarial, so that no sharp line can be said to exist between the 
 two eruptive types of erythema and urticaria. Histology furnishes 
 no data to explain the phenomenon of urtication. In simple primary 
 urticaria, an excised segment usually presents no lesion, provided 
 the blood-pressure and edema have disappeared ; sometimes, a slight 
 local polynucleosis is noted. [Gilchrist has found distinct evidences 
 of inflammatory changes even in the most recent wheals.] 
 
 As to the pathogenic mechanism, Torok and Vas have shown that 
 the fluid exudate in urticaria contains more albumin than that of 
 the mechanical edemas and is analogous to that of the inflammatory 
 exudates. The inflammatory or angioneurotic character of the 
 urticarias has been discussed by several foreign authors. Torok 
 and Philippson successfully produced experimental urticaria in 
 dogs, by inserting into the cutis capillary tubes filled with various 
 substances among which may be quoted: peptones, pepsin, trypsin, 
 cadaverin, putrescin, morphin, atropin, antipyrin, antidiphtheritic 
 toxin, staphylococcus toxin, etc.; hot water, formic, oxalic and uric 
 acids, syntonin, casein, etc., are said to be less active; while glyco- 
 coll, asparagin, purin derivatives, bilirubin, etc., are apparently 
 inactive. Possibly some of these substances which act in concen- 
 tration also play a part when they circulate in even infinitesimal 
 dilution in the blood. 
 
 More widely applicable and more conclusive are the experiments 
 which have demonstrated the anaphylactic character of the major- 
 ity of urticarias. For those which are produced by the sera (page 
 477), proof has been furnished by Arthus, Theobald Smith and 
 others. Reasoning by analogy, the same mechanism has been 
 invoked in all cases where injection or absorption of a foreign 
 albumin enters into consideration. Widal, in collaboration with 
 Abrami, Brissaud and Joltrain, has shown that in an attack of 
 alimentary urticaria, the cutaneous phenomena are preceded by 
 a set of blood and vascular phenomena, an actual "hemoclastic 
 crisis," identical with that of anaphylactic shock; a fall of blood- 
 pressure and a rapid leukopenia being its essential features. More- 
 over, the transmission of passive anaphylaxis to guinea-pigs has been 
 
48 URTICARIA 
 
 successfully carried out by Bruck, for urticaria due to pork, and 
 for the eruption following mussels, by Flandin and Tzanck working 
 in my laboratory. The watery fluid of hydatid cysts, which causes 
 urticaria and sometimes grave symptoms when effused into serous 
 cavities, although it is not poisonous has been shown to produce 
 anaphylaxis, by Chauffard, Boidin, Laroche and Deve. 
 
 Tims it becomes extremely probable that under a large number 
 of conditions, the susceptibility to urticaria consists in an ana- 
 phylactic state and that the determining cause merely liberates 
 the eruption. 
 
 Treatment. — In the first place, it is necessary to determine that 
 the urticaria does not depend upon an external cause, parasitic 
 or other. Acute attacks are suggestive of some article of food; 
 and a purgative and a strict diet based on the list of presumably 
 harmful substances (see Therapeutic Notes), with some local 
 applications may constitute sufficient treatment. 
 
 In the case of chronic urticaria, it behooves the physician to 
 investigate with care the general disturbances so as to remedy these. 
 Thorough hygiene of the nervous system and a strict alimentary 
 regimen, sometimes a closely prescribed diet, are imperative. 
 
 Internal medication may be required, such as calcium salts, 
 ferments or yeasts, ichthyol, salicylates, alkalis, mineral waters 
 or intestinal irrigations. The subcutaneous injection of 0.5 mg. 
 of adrenalin often attenuates the crises and repeated applications 
 have cured a few cases. [Immediate relief is often obtained by 
 the subcutaneous injection of 0.01 gm. of pilocarpin muriate.] 
 
 The remarkable efficacy of serotherapeutic treatment in some 
 cases of urticaria has attracted attention to the study of the differ- 
 ent forms of this method, but its results are not constant. Some- 
 times a rapid cure has been obtained by copious venesection followed 
 by intravenous injection of physiological salt solution, by the 
 injection of* serum from a healthy person, by autoserotherapy, by 
 the injection of animal serum in very minute doses. The need of 
 caution in the employment of these remedies cannot be overempha- 
 sized, as they are liable to aggravate the trouble. The procedures 
 designated to establish an anti-anaphylactic state have not yet been 
 formulated. 
 
 External measures, although constantly demanded by the patient 
 for the relief of the pruritus, are of minor importance. Baths and 
 douches, it is well to know, often aggravate the trouble; and 
 similarly ointments. Soothing acid or alcoholic lotions are prefer- 
 able and should be applied warm or cold, or rather lukewarm, with 
 a decoction of slippery elm, lime, or chamomile, or with a solution 
 of vinegar, lemon- juice, camphorated alcohol, carbolized glycerin, 
 menthol, thymol, resorcin, etc., followed by abundant applications 
 
URTICARIA FACTITIA, OR DERMOGRAPHISM 49 
 
 of neutral powders. The hygiene of the skin requires some atten- 
 tion; the underclothing should be light, of fine smooth texture and 
 must not rub or press on the skin. 
 
 Whatever the cause of the urticaria, the treatment should not be 
 schematic but should be specially adapted to the requirements 
 of the case. 
 
 GIANT URTICARIA. 
 
 Under this name, or that of acute circumscribed edema of Quincke, 
 an affection has been described which manifests itself by the sudden 
 appearance of edematous infiltrations, usually fairly well outlined, 
 firm, pinkish or porcelain-white in the center, with a rose-colored 
 periphery. These infiltrations have the size of a hazelnut, walnut, 
 or even an orange; their elevation may amount to several centi- 
 meters; they are the seat of a sensation of tension, burning or 
 itching. They may appear at any point of the integument or 
 even of the mucous membranes, although the face and the region 
 of the genital organs are the seats of predilection. 
 
 The attack comes on suddenly, often during the night, without 
 prodromata or with some malaise and a slight fever; a single eleva- 
 tion, or a small number, appear and persist for a few hours, at most 
 two days. The attacks may be periodically repeated or they may 
 be separated by intervals of variable length. 
 
 This affection persists for years, associated or not with common 
 chronic urticaria; it finally disappears, sometimes to become 
 replaced by other pathological manifestations. Its possible locali- 
 zation in the upper respiratory passages represents the only danger- 
 ous element. Also, according to the seat of the edema, the patient 
 may be disfigured for a few hours. 
 
 Etiology. — The etiology is the same as that of chronic urticaria. 
 There exist intermediate cases between this and Quincke's edema. 
 
 The paroxysms sometimes follow overeating, errors in diet, 
 nervous overstrain or the action of cold. In the interval, the 
 patient may enjoy excellent health. 
 
 Treatment.- — The treatment follows that of ordinary urticaria. 
 Simple calcium chloride, systematically administered, in courses, 
 has repeatedly proved entirely successful in my experience. 
 
 URTICARIA FACTITIA, OR DERMOGRAPHISM. 
 
 It has been stated above that in most cases of urticaria, the 
 eruption can be provoked at the time of the attacks by scratching 
 or other cutaneous irritations. Dermographism is an altogether 
 different phenomenon. In certain individuals, a mechanical irri- 
 tation, especially forcible friction with a blunt point gives rise to 
 4 
 
50 
 
 URTICARIA 
 
 a special cutaneous reflex, a non-pruritic urticarial elevation. A 
 very brief stage of anemia with prominence of the hair follicles, 
 is followed by the appearance of a bright pink line, which widens 
 to 1 to 2 cm., the middle becoming raised in less than a minute in 
 the form of a ridge. At the end of five minutes this ridge may 
 attain a height of 3 to 1 mm. and a breadth of 1 cm.; the phenome- 
 non usually lasts from fifteen to twenty minutes or sometimes 
 several hours. Although electrical stimulation or other irritations 
 may also cause its appearance, a mechanical action is most effec- 
 tive. Friction over the affected region, after the complete sub- 
 sidence of the phenomenon, may cause the reappearance of the 
 writing or designs which had been traced on the skin. 
 
 lographism 
 
 Dermographism is observed especially on the trunk and on the 
 first segments of the limbs. It is rare in the face, but is said to 
 have occurred on the buccal mucosa. 
 
 Dermographism is one of the stigmata of the neurotic constitu- 
 tion. It is met with in hysterical individuals, in epilepsy, in 20 per 
 cent, of the insane, especially among idiots and constantly in 
 catatonia ; furthermore, in the victims of lead poisoning and chronic 
 alcoholism, especially in consumers of aromatic liquors. In the 
 spring, during the menstrual periods and after emotions or fatigue, 
 dermographism is the most marked. It is noteworthy that it 
 
TREATMENT 51 
 
 does not often occur in association with common urticaria. Its 
 name of pseudo-urticaria is derived from the absolute objective 
 identity between the dermographic elevation and the urticarial 
 wheal. The suggestion has been made that the mysterious aspect 
 of this phenomenon may have led to its being used in former days 
 in the tricks of sorcerers. At the present day, malingerers have 
 utilized it for the simulation of some other eruption. 
 
 Treatment. — The treatment consists in attention to hygiene, if 
 necessary, and care of the general condition. 
 
CHAPTER III. 
 PURPURA. 
 
 The name purpura is applied to an eruption of spontaneous 
 hemorrhagic spots. The spots of purpura are of a bright or bluish 
 red and do not disappear under pressure of the finger; they are 
 usually of rounded shape, flat or slightlv elevated, of variable 
 extent, more or less numerous, but always multiple. 
 
 Petechia is the term in use for the description of small punctiform 
 or lenticular lesions; they sometimes surround the pilo-sebaceous 
 orifices. Ecchymoses are more extensive and irregular; they vary 
 in size from that of a coin to that of the hand, or more. A less 
 common term, vibices, designates more elongated or striated 
 purpuric spots. 
 
 After a few days or weeks, depending on their size, these hemor- 
 rhagic spots fade away, after having passed through the same 
 shades, purplish, brownish, greenish and yellowish, as the traumatic 
 ecchymoses. 
 
 Petechia 1 are highly characteristic, being necessarily spontaneous; 
 ecchymoses may have been produced by a forgotten or wilfully 
 denied traumatism, sometimes very insignificant in the victims of 
 hemophilia. 
 
 Purpuric spots must not be confused with vascular nevi, which 
 are of indefinite duration; nor with the spots of erythema, which 
 fade away under pressure of the finger. 
 
 The combination of erythema with different varieties with pur- 
 pura, either in the same spot as the hemorrhages or coincidently in 
 the same region, is not unusual. The purpuric spots may also be 
 urticarial at the onset (purpura urticans) or become complicated 
 by urticaria. 
 
 We must therefore admit an obvious relationship, transition- 
 forms and various combinations, between purpura, erythema and 
 urticaria (such as erythema nodosum contusiforme, urticaria hemor- 
 rhagica, etc.). 
 
 The term purpura should not be applied to occasional hemor- 
 rhagic eruptions, such as occur in smallpox, herpes zoster, eczema, 
 pemphigus and the pyodermatitides. Such conditions are properly 
 described as hemorrhagic variola, etc. 
 
 The eruption of purpura comes on in sudden or prolonged attacks, 
 which arc frequently successive. The attack may be preceded by 
 
CLINICAL FORMS 53 
 
 inflammatory local edema, sometimes lymphangitic, of short dura- 
 tion and accompanied by heat or pruritus, or it may occur without 
 the patient's knowledge. The affected region appears irregularly 
 dotted with lesions, all of the same size or of different sizes, of 
 the same age or at different stages of their development. 
 
 The distribution of purpura is often more or less symmetrical; 
 the lower limbs are most commonly and sometimes alone affected, 
 or sometimes all the extremities are involved. The eruption may 
 occupy any location and may even invade the mucous membranes, 
 where it is apt to assume the form of blood blisters which rupture 
 and give rise to hemorrhage. 
 
 In some cases of purpura, it is possible to produce a hemorrhagic 
 spot through moderate pressure on the skin with a blunt point 
 (provoked purpura), or an eruption of petechia? through the tempo- 
 rary constriction of a segment of the limb (tourniquet purpura) . 
 
 Clinical Forms. — The eruption of purpura is sometimes merely 
 a commonplace symptom of several pathological conditions; these 
 cases are described as secondary purpuras. Again, it may form 
 part of one of the syndromes designated as primary purpuras, 
 representing their most salient feature. 
 
 As a matter of fact, purpura occurs under very different condi- 
 tions; occasionally ia the midst of health and without an appreciable 
 determining cause; or as a sequel of overstrain, or after intoxica- 
 tions; or in the course of definite infectious diseases or cachexias. 
 It may furthermore be associated with a train of general phenomena, 
 among which rheumatoid pains, gastro-intestinal disturbances, 
 fever, general malaise, etc., are especially common. 
 
 On the one hand, the purpuric eruptions may occur without 
 hemorrhage from the mucosa?, constituting purpura simplex. On 
 the other hand, it may be accompanied by very profuse epistaxis, 
 bleeding from the buccal mucous membranes, especially the gums, 
 metrorrhagia, melena, hematuria or visceral hemorrhages, consti- 
 tuting purpura hemorrhagica. 
 
 This division, for which we are indebted to Willan, can only be 
 maintained from the descriptive point of view, for it does not 
 correspond to a difference in etiology; a simple purpura may at 
 any time become transformed into purpura hemorrhagica. It is 
 not even in harmony with the prognosis, purpura hemorrhagica 
 being sometimes benign and at other times grave. 
 
 It seems more rational to base the establishment of the clinical 
 types on the question of whether the purpura is a simple symptom 
 or whether it constitutes a syndrome. 
 
 Great differences of opinion on this point exist among authors. 
 The following forms are generally admitted, although under different 
 designations : 
 
:>i PURPl RA 
 
 SECONDARY PURPURAS. 
 
 The secondary purpuras arc those which appear as an ordinary 
 symptom or epiphenomenon in the course of a large number of 
 pathological conditions. They possess an indicative value, but are 
 of little importance in themselves. 
 
 Four classes of these purpuras are recognized: 
 
 1. Mechanical "purpuras, which occur on the limbs under the 
 influence of prolonged constriction, or at any point of the body in 
 the course of asystole [in a disturbance of cardiac compensation] 
 or of lits of whooping-cough or attacks of epilepsy. 
 
 2. Toxic purpuras, which may be provoked by certain medicinal 
 agents such as phosphorus, potassium iodide, mercury, arsenic, 
 antipyrin, chloral, salicylates, quinin, belladonna,, ergot, copaiva, 
 etc., as well as by injections of antitoxic sera, bites of venomous 
 serpents, etc. 
 
 3. Secondary purpura of the acute infection* diseases, such as 
 angina, diphtheria, scarlet fever, gonorrhea, typhoid, typhus, 
 miliary tuberculosis, malaria, etc. 
 
 1. Cachectic purpuras, observed at advanced stages of serious 
 diseases, cancer, tuberculosis, Bright's disease, hepatic cirrhosis, 
 icterus gravis, pernicious anemia, the leukemias, etc. The erup- 
 tion usually comes on insidiously, without inflammatory phenomena, 
 sometimes with edema and occupies chiefly the lower extremities. 
 
 The group of cachectic purpuras is really most heterogeneous 
 and many cases are probably referable to an infection, auto-intoxi- 
 cation, nervous lesions or anomalies of the blood. 
 
 Purpura senilis- of Bateman has sometimes been grouped under 
 the same heading. r l nis designation is applied to purpuric spots 
 which occur incessantly, for years, without general disturbances, 
 in aged individuals; located predominantly on the forearms. Unna 
 and Tasini have shown that these cutaneous hemorrhages are related 
 to senile degeneration of the skin. 
 
 PRIMARY PURPURAS. 
 
 The primary purpuras are those in which the petechia' and 
 ecchymoses, with or without hemorrhages of the mucous mem- 
 branes, represent the exclusive or principal phenomenon. Several 
 types are recognized : 
 
 1. Rheumatoid purpura is the most common; it is identical with 
 Schoenlein's peliosis rheumatica and the myelopathic purpura of 
 Paisans. 
 
 It occurs in both sexes but more frequently in youthful or adult 
 males and is supposed to follow on exposure to damp, cold, fatigue, 
 
PRIMARY PURPURAS 55 
 
 overstrain or emotional disturbances. The onset is often marked 
 either by a sensation of fatigue or articular pains in the lower 
 limbs, or by a more or less extensive transitory edema in the same 
 regions, or finally by gastro-intestinal disturbances. Fever is 
 variable, not high and may be absent. 
 
 The rheumatoid pains are arthralgic, associated or not with 
 articular swelling; they affect the knees and ankles especially, but 
 may extend to the joints of the upper extremities. 
 
 Sometimes the pain is muscular or neuralgic. The distinction 
 between these rheumatoid naiiis and those of acute rheumatism has 
 been emphasized by Besnier. 
 
 The gastro-intestinal disturbances consist in repeated vomiting 
 with gastralgia, in intestinal colics, often severe, simulating the pains 
 of peritonitis, or accompanied by diarrheal crises, melena, or dys- 
 enteriform evacuation. These various manifestations precede or 
 accompany the eruption and are temporary, but may sometimes 
 recur in the course of the disease. Various complications have been 
 noted on the part of the serous membranes and the viscera. 
 
 The eruption consists of petechia, more or less mixed with small 
 ecchymoses; it affects especially the lower limbs symmetrically 
 (Fig. 6), but may become generalized, beginning with the upper 
 limbs. Not infrequently, it is polymorphous, mixed with papular, 
 nodular, or urticarial erythema. The name of purpura exanthe- 
 matica is used by Laget for this eruptive complex. 
 
 The attacks recur at very irregular intervals. They are sometimes 
 so obviously aroused by posture or walking as to justify the expres- 
 sion of "orthostatic purpura." Periodical attacks coinciding with 
 the menses have also been observed. 
 
 The majority are cases of purpura simplex. Hemorrhages are 
 rare, but may supervene in the course of evolution, aggravating 
 the clinical picture. 
 
 The duration of the disease is ordinarily a few weeks; but some 
 cases are prolonged for several months. Recurrences may take 
 place at irregular intervals. 
 
 The severity of the systemic symptoms varies within extreme 
 limits; sometimes they have to be looked for, or, on the contrary, 
 they may have the appearance of a grave infection. 
 
 Sporadic scurvy, only rare cases of which are now met with, 
 differs from rheumatoid purpura by its etiology, which involves 
 confinement and deprivation of fresh foods, as well as by the swollen 
 condition of the gums and the well-marked anemia and asthenia. 
 These cases, however, may be interpreted as rheumatoid purpura 
 developing in a prepared soil. 
 
 In infantile scuroy or Barlow's disease, the ecchymosis and hemor- 
 rhages of the mucous membranes are far from constituting the most 
 
56 
 
 Pl'RPT 'HA 
 
 important feature of the clinical picture, in which painful pseudo- 
 paralysis [due to involvement of the joints] predominates. 
 
 Although apparently primary, the cases of chronic purpura, 
 reported especially by Hayem and his school, as well as by Millard 
 and others, are probably of autotoxic origin or connected with a 
 more or less latenl infection, such as tuberculosis. The continuous 
 or intermittent cutaneous and hemorrhagic manifestations mav be 
 
 Purpura rheumatoides 
 
 prolonged for ten or twenty years, the prognosis being nevertheless 
 regarded as relatively favorable. This form must not be confused 
 with hemophilia, which is congenital and hereditary and in which 
 the coagulability of the blood is always markedly diminished. 
 
 I nderthe name of purpura annularis telangiectoides, a well-defined 
 clinical type was described by Majocchi, in 1895, and has since been 
 studied by several authors. It consists of dull red spots, symmetri- 
 cally distributed on the lower limbs especially, at first telangiectatic, 
 
PRIMARY PURPURAS 57 
 
 then hemorrhagic and becoming ring-shaped through gradual cen- 
 trifugal extension. Pasini attributes these spots to endophlebitis 
 of the small, deep veins of the skin. The etiology of this dermatosis 
 is entirely unknown. 
 
 2. Primary infectious purpuras are those in which the general 
 symptoms indicate an infection of the type of septicemia. Besides 
 relatively attenuated forms, which form a connecting link with 
 rheumatoid purpura, there occur very grave forms, such as the 
 angiohematic typhus of Landouzy and Gomot, and the purpura 
 fulminans of Henoch. 
 
 Such cases may begin with a severe initial chill, vomiting, a tem- 
 perature of 40° [104°], typhoid stupor, delirium, coma, dry tongue, 
 albuminuria and sometimes .icterus, together with scattered petechia 
 and ecchymoses and hemorrhages from various avenues. The pur- 
 puric lesions may become gangrenous; cellulitis, purulent arthritis, 
 etc., may occur. Several of these cases have recently been traced 
 to infection by the meningococcus, the presence of which in the blood 
 and in the spots has been demonstrated by A. Netter and Salanier. 
 Death may follow in two or three days in the acute variety; or in 
 one or two weeks, in the typhoid variety. 
 
 3. Abrupt apyretic purpura hemorrhagica, or morbus maculosus — 
 two typical instances of which were published by WerlhofT — is a 
 rare form. According to a generally accepted standard, its behavior 
 is as follows: 
 
 In the midst of health, sometimes after an emotion or slight 
 traumatism, often without prodromata or malaise, without fever, 
 a slight nasal or gingival hemorrhage makes its appearance. On 
 the next day, petechia are noted on the lower limbs, then larger 
 scattered ecchymoses together with hemorrhages from various 
 mucous membranes. After ten to fifteen days, recovery sets in 
 without complications. Neither infection nor intoxication, nor a 
 grave lesion of the blood have been demonstrated in the course of 
 the disease. 
 
 It appears more and more probable that a considerable number 
 of the clinical forms of purpura discussed above, notably the primary 
 purpuras, the secondary purpuras following infectious diseases 
 and even some of the so-called cachectic purpuras, do not constitute 
 distinct diseases, but merely degrees or variations of the same 
 morbid process. Interpreted in this manner purpura, simple or 
 hemorrhagic, would be merely the consequence of various acute or 
 chronic infections, causing alterations in the composition of the 
 blood and vascular or visceral lesions which in turn are responsible 
 for the different aspects of the syndrome. 
 
58 PURPURA 
 
 Pathogenesis. Purpura is observed in both sexes, at any age, 
 under a great variety of conditions as referred to above. 
 
 Pathological Anatomy. — Pathological anatomy teaches that the 
 purpuric spots always contain an effusion of blood, with its white 
 corpuscles; situated at a variable level in the meshes of the derma 
 or hypoderm up to the papillae, where it undergoes the usual changes 
 of extravasated blood. Sack has shown that vascular rupture most 
 frequently occurs in the small veins of the subdermal plexus. The 
 vascular walls, although various changes and degenerations have 
 been reported, are nearly always in a remarkably intact condition. 
 
 In the absence of local lesions to account for the hemorrhages, 
 different general conditions have been invoked, which, however, 
 do not exclude one another. 
 
 In the circulating blood, the number of red cells remains normal, 
 except in case of profuse hemorrhages, or pernicious anemia; the 
 number of white corpuscles is rarely changed (leukemias) ; the blood 
 platelets — according to Denys, Hayem, Bensaude and others, con- 
 firmed by W. Duke — may become very scanty, or even entirely 
 disappear (L. Le Sourd and Pagniez). As to humoral lesions, a 
 retarded or normal coagulation of the blood, a non-contracting or 
 imperfectly contractile and friable clot and an increased red blood 
 cell resistance has been noted. The "bleeding time" (W. Duke) 
 may be greatly increased. However, these various phenomena are 
 inconstant; their importance, mutual relations and pathogenic 
 significance are still under investigation. 
 
 Viscera] lesions are common. Those of the liver and kidney may 
 be charged with having prevented the destruction or the elimination 
 of certain toxins; on the other hand, the role of the hepatic function 
 in the coagulation of the blood is well known. Changes in the intes- 
 tinal tract arc frequently found in the purpuras, as shown by clinical 
 observation and autopsies; 1 believe that the intestinal tract is often 
 the starting-point of the infection or intoxication to which the 
 purpura is due, perhaps through intermediation of the liver which 
 is damaged in transit. A form of abdominal purpura has even been 
 described (Henoch). A pathological condition of the suprarenal 
 glands and hi Ivessel glands has sometimes been held responsible. 
 
 The role of the nervous system is shown by a large number of 
 facts. The rheumatoid pains characteristic of certain primary 
 purpuras have been referred to above. Petechial eruptions have 
 been observed in the course of myelopathies and neuritis. Straus 
 has noted their coincidence with the fulminating or lightning pains 
 of tabes. There are cases of purpura involving only one-half of the 
 body, or even in exceptional cases assuming a metameric or radicular 
 distribution, proving at any rate a localizing influence of the nervous 
 system. Spinal puncture sometimes, but not invariably, reveals a 
 
PRIMARY PURPURAS 59 
 
 lymphocytosis of the cerebrospinal fluid. Finally, Grenet has suc- 
 ceeded in the experimental production of purpura in rabbits, by 
 first damaging the liver and then injecting toxins into the spinal 
 cord. 
 
 The possible effect of intoxications is illustrated by the existence 
 of the toxic purpuras, which have been mentioned. A probable 
 influence of auto-intoxications and perhaps of microbic toxins may 
 be inferred. 
 
 Infection, as I have intimated, is probably responsible for all the 
 non-toxic forms of purpura. Originally asserted by Hayem, this 
 fact has been established by clinical observation and laboratory 
 research in a group of cases and is very probable for the remainder, 
 including the so-called neuropathic, dyscratic, or cachectic purpuras. 
 Moreover, the literature contains a very considerable number of 
 cases where the staphylococcus, streptococcus, pneumococcus, pyo- 
 cyaneus, meningococcus, etc., have been demonstrated either in 
 the purpuric spots or in the circulating blood. These facts tend to 
 show that a variety of infections may manifest themselves in the 
 clinical picture of purpura. 
 
 It is possible, but by no means an established fact, that there 
 exists a specific microbe, more apt than others to produce the patho- 
 logical picture of infectious purpura. This would serve to explain 
 the cases of epidemic and contagious purpuirc fever, mentioned by 
 some authors, the occurrence of which, however, is somewhat 
 doubtful. 
 
 Treatment.— Any case of purpura, even when its onset is appar- 
 ently most harmless, must be carefully watched, as it is impossible 
 to foretell when and how it will end. These patients should accord- 
 ingly be put at rest, under good hygienic conditions, on strict diet 
 and in the open air if possible. For the control of the hemorrhages, 
 the old medication with acids, ratanhia, hamamelis, ergotin, iron 
 perchloride, is now abandoned, experience having shown them to be 
 utterly useless. They have been replaced by modern agents, such 
 as gelatin, calcium chloride, injections of peptones and blood-sera, 
 hepatic and suprarenal extracts, adrenalin, pituitrin, etc. 
 
 The results obtained in the treatment of hemophilia and hemo- 
 globinuria have led to experimentation with methods acting on the 
 equilibrium of the blood, modifying its coagulability and producing 
 what Widal has described as the "hemoclasic crisis." Injections 
 of horse-serum, in large amounts, or in moderate or minute repeated 
 doses, as well as autoserotherapy, have their advocates. [A careful 
 search must be made for occult sources of infection with special 
 attention to the teeth and the tonsils.] These methods, which do not 
 exclude adjuvant medication, especially with calcium salts, have 
 yielded very encouraging results, but their indications have by no 
 means been definitely formulated. 
 
CHAPTER IV. 
 ECZEMA. 
 
 The eruption known as eczema is not characterized by a single 
 eruptive element, but by a series of elementary lesions which suc- 
 ceed each other, combine or coexist in neighboring localities. These 
 lesions are the result of an inflammatory process, affecting the epi- 
 dermis and cutis ; an epidermo-dermatitis, comprising several stages 
 which are of equal importance. 
 
 Clinically, these stages are manifested under the following aspects: 
 erythema, resiculation, exudation, crust formation, lichenization and 
 desquamation. 
 
 Histologically, the lesions consist, in the epidermis, of spongiosis, 
 acanthosis and parakeratosis; in the cutis, of congestion, edema and 
 moderately abundant cellular infiltration. 
 
 This definition must be supplemented by mention of the three 
 characteristic features of the eruption: its usual arrangement in spots, 
 patches, or surfaces with irregular outlines (insular, geographical or 
 archipelagous) ; its development in crops or relays, with a tendency 
 to peripheral extension and often to a chronic state with fresh 
 exacerbations and its more or less pruritic character. 
 
 Defined in this way, the eczematous process is one of the most 
 easily recognized. It must be appreciated, however, that this proc- 
 ess is not limited to a single and specific dermatosis, but on the 
 contrary represents a relatively common mode of reaction of the 
 skin toward a series of mechanical, physical, parasitical and microbic 
 i nit ants. This reaction must be considered in all respects as 
 inflammatory. 
 
 Eczema, Eczematization, Eczematosis. —The subject of eczema 
 lias become extremely complicated and much confusion has been 
 caused by the application of the term eczema for some time to 
 absolutely different conceptions. Eczema was interpreted by Hebra 
 and the Vienna school of dermatologists, as a very common poly- 
 morphous affection, which may at any time be artificially produced 
 in any person. According to the French school, on the other hand, 
 eczema was a rare disease, especially in the clinical material of 
 hospitals, incapable of being artificially produced, since it implies 
 the existence of a general predisposition — altered tissue-juices — 
 a diathesis. Hence, two entirely distinct groups of facts had to be 
 dealt with. Besnier, in 1S92, was perhaps the first to elucidate 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 61 
 
 the controversy by creating the word eczematization to designate the 
 eczema of Hebra-Kaposi, which is not a disease but an eczematoid 
 artificial dermatitis. The eczema of French writers, on the contrary, 
 is a true disease, which although having multiple causes is related to 
 a peculiar condition of the individual; this disease is chronic and 
 recurrent. The eruptive manifestation of eczematous disease is 
 identical with that of eczematous lesions, or eczematization. 
 
 The question would thus seem to have become quite clear, but on 
 closer examination considerable difficulties of interpretation are 
 encountered. If several persons be subjected to the same external 
 irritant, for example, rubbing with spirits of turpentine or tincture 
 of arnica, some will experience at the injured point a transitory 
 erythema or a dermatitis in the form of eczematization with a 
 marked tendency to subsidence; in others, this dermatitis will be 
 extensive and may even become generalized, then healing more or 
 less rapidly; and finally, in others, its duration will be prolonged, 
 recurrences supervening on slight causes or even in the absence of 
 an appreciable cause and this abnormal condition may occasionally 
 persist throughout life. 
 
 Several suggestions have been made in explanation of these 
 differences in the evolution of the lesions. It has been claimed that 
 an eczematization produced by contact with an irritant, no matter 
 what its evolution and duration, is and remains an artificial eczema- 
 toid dermatitis, there being only an objective and apparent identity 
 between it and the disease eczema dependent on a diathesis. This 
 interpretation would necessarily lead to grouping absolutely similar 
 clinical pictures under different headings and to basing the diagnosis 
 on the patient's statements or on an estimate of the irritative proper- 
 ties of the supposedly provoking causes. 
 
 It has also been stated that an ordinary eczematoid dermatitis 
 may become transformed into a specific dermatitis; but this can 
 hardly be admitted, as it is not known wherein the specificity of the 
 disease eczema lies. 
 
 Obviously, on the contrary, the persons of the first group in the 
 above-mentioned example, were in a state of physiological integrity, 
 investing them with relative immunity toward the injurious agent, 
 whereas, pathological conditions creating a morbid tendency existed 
 in the others. Those who were affected in the most severe and per- 
 sistent manner were eczematous subjects in whom a local irritation 
 sufficed to bring out a hitherto latent disease. Although this is 
 entirely plausible, it must be added that, keeping in mind the very 
 variable evolution of eczematous dermatitis of artificial origin, one 
 is forced to admit an entire scale of subnormal and abnormal states, 
 creating a more or less marked predisposition for the appearance, 
 persistence and recurrence of the eczematous eruption. 
 
62 ECZEMA 
 
 Thus all distinct boundaries or fundamental differences between 
 eczematization or artificial eczematoid dermatitis with a rapid 
 
 tendency to spontaneous cure and true eczema, a chronic recurrent 
 disease, are obliterated. It is now merely a question of degree and 
 there remains no valid reason for withholding the name of eczema 
 from any eczematization, whether of artificial or of apparently 
 spontaneous origin. 
 
 The term eczema will therefore be applied in this book to all 
 eruptions corresponding to the definition at the beginning of this 
 chapter. This name will be supplemented by qualifying adjectives, 
 referring to the momentary objective appearance (vesicular, exuda- 
 tive, crusted eczema, etc.), or to the evolution (acute, chronic, 
 recurrent eczema), or to the apparent etiology (artificial, occupa- 
 tional, microbic eczema, etc.). 
 
 I propose the term eczematosis for the chronic pathological con- 
 dition described by other authors as constitutional eczema, eczema- 
 disease or true eczema. 
 
 I shall speak of secondary eczematization, or of an eczematized 
 dermatosis, when a dermo-epidermatitis of eczematous type becomes 
 superadded to the lesions of a preexisting dermatosis (example: 
 eczematized prurigo, eczematized psoriasis, etc.). 
 
 Finally, as will be seen in the next chapter, I call eczematides the 
 dry eczemas, the eczema seborrhoeicum or seborrheids of other 
 authors. 
 
 Pathological Anatomy. — Eczema being an inflammatory patho- 
 logical process clinically manifested by very variable objective 
 appearances, the nature of their process must be studied in detail 
 before describing the manifestations. 
 
 1 . The chief lesion of eczema is an edema of the Malpighian body; 
 the serous fluid infiltrates between the epidermic cells, stretching 
 their connecting filaments, so that the rete assumes an appearance 
 which is very properly denominated as a spongioid state, by I Tina, 
 and as spongiosis, by Besnier. 
 
 2. When in the spongioid state, the fluid has sufficient pressure 
 to rupture the connecting filaments of the Malpighian cells, it collects 
 in vesicles, cavities filled with a transparent fibrinous plasma, con- 
 taining a few wandering cells and bounded by epidermic cells which 
 have been pushed aside and sometimes compressed. These vesicles, 
 which at first are very small, originate in the deep layer of the epi- 
 dermis; they increase in size an 1 become confluent with neighboring 
 vesicles until they are visible to the naked eye and protrude under 
 the horny layer; ultimately vesicles form at all levels in the rete; 
 the oldest arc pushed up toward the surface by the outward growth 
 of the epidermis and new ones are often formed beneath them. 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 
 
 G: : i 
 
 The vesiculation of eczema is therefore interstitial and dependent 
 on the spongiosis, therein differing from the vesiculation of zona, 
 varicella, etc. 
 
 The ultimate fate of eczema- vesicles is variable; they terminate 
 by desiccation or rupture, or become secondarily infected. 
 _ 3. The first contingency, desiccation without oozing or suppura- 
 tion, may eventuate, no matter what the size of the vesicles, in 
 regions where the epidermis is resistant. It gives rise to tiny 
 crusts or larger crusts, composed in variable proportions of dried 
 serum, the remains of parakeratotic cells and collections of microbes. 
 The epidermis reforms below and the crusts are shed. Desiccation 
 of the foci of spongiosis is the rule in certain forms having a rather 
 peculiar clinical appearance and course, so that they have been 
 separated from the group of moist eczemas under the name of dry 
 eczemas or seborrheal eczemas. They will be described further on 
 under the name of eczematides (p. 90). 
 
 Fig. 7. — Histology of eczema. X 45. A, infected vesicle; B, crust; C, parakera- 
 tosis; D, acanthosis; E, papillary edema; F, vesicle; G, spongiosis; H, perivascular 
 infiltration. 
 
 4. When the vesicles have ruptured spontaneously or under the 
 influence of scratching or rubbing, their contents are poured out 
 externally and there is weeping or oozing. In weeping eczema, 
 the escape of serous fluid is often prolonged, without production of 
 new vesicles, because the fluid of the spongiosis which is incessantly 
 reproduced, finds a way of escape through the open cavity of the 
 ruptured vesicles; these constitute the eczematous pores. The process 
 of keratinization being altered, as will be shown further on, a rapid 
 cicatrization of these orifices cannot occur. 
 
 5. The vesicles of eczema may be microbic from the start, or they 
 may be originally sterile. In the latter case, they are easily infected 
 by pyogenic microbes, which find them an excellent culture medium 
 
64 ECZEMA 
 
 to which they attract an abundance of polynuclear leukocytes. This 
 is known as impetiginization (p. 162). 
 
 In these infected or impetiginous eczemas, the fluid is turbid or 
 purulent and dries in thick mclicerous crusts, under which the 
 epidermis remains deeply eroded; moreover, the increased viru- 
 lence of the microbes, once they begin to grow, leads to a peripheral 
 extension of the lesions and their remote propagation in the form 
 of microbic eczema or of true impetigo. 
 
 (>. Coincidently with the spongiosis, the Malpighian edema gives 
 rise to the change of keratinization known as parakeratosis; this is 
 characterized by the disappearance of the stratum granulosum 
 and preservation of the nuclei in the cells of the homy layer, which 
 contains less fat than in the normal state. In a general way, the 
 parakeratosis controls desquamation and it accordingly predomi- 
 nates in the squamous, lamellar, psoriatiform , "craquele," u corne," 
 hyperkeratotic eczemas, etc. 
 
 7. The spongiosis and the vesiculation, or rather more probably the 
 persistence of the causes which have started and maintained them, 
 lead at the end of a certain time to an abnormal multiplication of 
 the Malpighian cells, hence thickening of the rete; this process is 
 called acanthosis. The mterpapillary pegs are enlarged and the 
 papillae are proportionately elongated and narrowed, although fre- 
 quently edematous. This thickening of the epidermis and of the 
 papillary body results in the appearance of the so-called lichenoid 
 eczema. The papillary body in such cases is usually the seat of 
 more or less abundant infiltration. 
 
 8. The fluid or plasma of this intra-epidermic edema, which is 
 seen to govern practically the entire eczematous process, is obviously 
 derived from the cutis, where it is exuded from the congested and 
 dilated bloodvessels of the papillary body. 
 
 The epidermic lesions described above are accordingly preceded 
 by dermic lesions, consisting of hyperemia and edema of the papil- 
 lary body, with moderate diapedesis of white corpuscles mixed 
 with a few red cells, which accumulate as a perivascular infiltration. 
 These lesions manifest themselves clinically by redness and swelling, 
 the symptoms being sometimes slightly marked, but in other cases 
 constituting the most obvious phenomenon, for example in acute 
 eczema of the face and in eczema rvbrum. 
 
 Of the various elementary anatomical lesions the most essential 
 are: spongiosis, parakeratosis and acanthosis; all others depend on 
 them. They may become combined or associated, or succeed each 
 other in such a way as to give rise to the multiple aspects which 
 eczema may assume. It must be kept in mind that the qualifying 
 terms vesicular, exudative, squamous, etc., do not designate species 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 65 
 
 or even varieties of a distinct type, but only accidental, temporary, 
 or more or less persistent phases. 
 
 General Etiology. — Considered as a whole, eczema is the most 
 common of all cutaneous affections. Its different varieties and 
 localizations make up nearly one-third of dermatological practice. 
 [In the statistical reports of the American Dermatological Associa- 
 tion, covering about three-quarters of a million dermatoses, the 
 eczemas, including eczematides, comprise about 20 per cent, of 
 the total.] It is observed at all ages; during early childhood 
 {infantile eczema), then in the period of active life (occupational 
 eczemas), finally in the stage of decline of organic resistance (senile 
 eczema). The two sexes are equally susceptible and no social class 
 is immune. 
 
 Its causes may be divided into external, determining, or occasional 
 and internal or predisposing. 
 
 External Causes. — These are innumerable. Nearly all local irri- 
 tants of any kind, whose moderate influence excites erythema, are 
 capable of causing eczema when their action is augmented. It 
 must be noted, however, that these agents are eczematogenous 
 to a variable degree, some of them requiring a more decided pecu- 
 liarity or cooperation of the organic soil. Predisposition therefore 
 has a bearing not only upon the extent and duration of the reaction, 
 but upon its character also. 
 
 Among the local factors of eczema must be mentioned mechanical 
 agents, such as scratching; physical agents, such as a bright light 
 (Wilson's eczema solare), heat (eczema caloricum); and countless 
 chemical irritants (arnica, turpentine, phenol, etc.). The majority 
 of these injurious factors will be considered in the chapter on the 
 artificial dermatoses (XXIII). Only a few causes of particular 
 interest will be discussed in what follows: 
 
 Traumatic Eczema from Scratching. — Eczema causes itching; the 
 scratching of the eruption, often evidently aggravates it and in some 
 cases may be responsible for its extension and dissemination. The 
 question arises under these circumstances whether the scratching 
 served to transport the irritative agent or the microbes which had 
 invaded the primary focus, or if the skin was directly eczematog- 
 enous as a result of individual prediposition. This dissemination 
 was regarded by Kaposi as the effect of an eruptive reflex. In 
 another group of cases, scratching is primary as compared to the 
 eruption; this is the case, for example, in pruritus and prurigo (pp. 
 481 and 488), in scabies and pediculosis, also I believe in ichthy- 
 osis, in the circulatory disturbances of the lower limbs, etc. There 
 exists accordingly a true traumatic eczema. 
 
 Parasitic Eczemas. — Aside from pruritus, or under conditions 
 where scratching is impossible, parasitic affections may give rise to 
 5 
 
66 ECZEMA 
 
 genuine eczematization. The eczemas of scabies and pediculosis 
 may therefore be referable either to scratching or to the virus of 
 the parasites. 
 
 In trichophytosis of hairless parts, the type known as herpes 
 circinaius where pruritus may be almost entirely absent, vesicles 
 due to spongiosis arc observed, followed by parakeratotic desqua- 
 mation. It seems to me justifiable to consider these as eczematous 
 and to attribute them directly to the fungus in the majority of the 
 cases. 
 
 Microbic Eczemas. — The question as to the part played by 
 microbes in eczema has been raised only relatively recently. 
 Twenty-five years ago nobody suspected that it would ever arise; 
 and certain modern writers have probably exaggerated its impor- 
 tance. 
 
 Unna regards eczema as a microbic dermatosis; the non-microbic 
 affections which simulate it are eczematiform eruptions, for the 
 most part artificial dermatitides, but not true eczema. The 
 pathogenic parasite of eczema in his opinion is the morococcus, or 
 the morococcic group; this is the name applied by him to the cocci 
 which are found in mulberry-like collections under the roof of the 
 vesicles. Later studies have identified these morococci with certain 
 staphylococci (p. 536). 
 
 As a matter of fact, it has been established by careful investi- 
 gations- among which those of Veillon, Sabouraud, Halle and 
 Civatte are specially mentioned because I personally assisted in 
 their work — that the vesicles of dermatoses which must be regarded 
 in all respects as eczemas, are primarily amicrobie, in the case of 
 artificial eczemas as well as of constitutional eczemas. These 
 vesicles may become infected secondarily by the ordinary microbes 
 of the skin. 
 
 On the other hand, these microbes are undoubtedly capable of 
 exciting the reaction of eczematization when they invade the 
 epidermis through the agency of mechanical, physical or chemical 
 traumatization, or of macerating lesions of the protective horny 
 layers; or of an abnormal structure of this layer and its adnexa, as 
 occurs in ichthyosis and especially in kerosis (XI); or of local or 
 regional circulatory disturbances, as in varicose eczema; and finally, 
 even on the normal skin, when they have acquired an increased viru- 
 lence through culture, in impetigo or any kind of wound, fissure, 
 fistula, etc. 
 
 In eczema of war /rounds, described by me as paratraumatic 
 eczema (p. ".">), countless instances of which have recently been met 
 with, these various conditions were generally associated; the lesion 
 of the epidermis produced by iodin, peroxide water or other anti- 
 septics, maceration through the dressings, local circulatory dis- 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 67 
 
 turbances, contamination of the surface by the pus of the wound or 
 fistula, combining to produce a genuine type of microbic eczema, 
 more or less impetiginous. 
 
 The facts adduced in favor of the general parasitic theory of 
 eczema (Unna, Leredde) are capable of other interpretations. 
 This is true for the auto-inoculation of eczema by scratching, etc.; 
 its recrudescence from imperfectly extinct foci; the peripheral 
 extension of eczematous patches; the identity of eczematous pro- 
 cesses irrespective of the apparent causative agent; and the some- 
 times easy curability by germicidal local applications. But these 
 facts nevertheless constitute a set of impressive arguments, to which 
 may be added a few observations, due to Unna, of positive inocu- 
 lation of microbic cultures derived from eczema, which produced 
 an eczematiform lesion in healthy inoculated subjects. 
 
 Briefly, there exists an assembly of clinical data and laboratory 
 findings, which prove the existence of an eczema of microbic origin 
 and character. It is certain that various microbic species, especi- 
 ally belonging to the staphylococcic group, may be eczematogenous. 
 Perhaps there exists a still unknown microbe which more than 
 others possesses this property. At the present writing, however, 
 it is not possible to state that definite species of microbes corre- 
 spond to the different forms and types of eczema. 
 
 We are especially ignorant of the degree to which infection is 
 responsible for eczema (for example in the artificial dermatitides, 
 in eczema from scratching, in parasitic eczema, in the dissemina- 
 tion of eczema), for up to the present time the clinician can no 
 more recognize in a given case whether the eczema is microbic or 
 not, than the bacteriologist can determine whether the detected 
 microbe is primary or of secondary implantation. 
 
 Internal Causes. — The general pathological conditions usually 
 met with in cases of eczema, and which may be suspected of being 
 internal or predisposing causes of this dermatosis, are the following : 
 Heredity is often invoked and is said to be either direct, when the 
 patient's parents were likewise eczematous, or indirect, when they 
 suffered from obesity, diabetes, gout, rheumatism, lithiasis, asthma 
 or migraine — briefly, from one or more of the multiple manifesta- 
 tions of the nutritional disturbance known [in France] as arthritism. 
 In other cases, the parents were inebriates, or exposed to various 
 intoxications, neurotic, overworked, etc. 
 
 The hygienic antecedents of the patient himself are sometimes 
 distinctly bad, whether in regard to the abuse of stimulants, alcohol, 
 coffee, tea, tobacco, etc., or to an excessive nitrogenous diet, over- 
 eating, or food of an inferior quality, or to nervous strain in all its 
 forms. 
 
 Still more frequently, auto-intoxications are responsible, due to 
 
fiS ECZEMA 
 
 gastric or intestinal dyspepsia, chronic enteritis, constipation, etc. 
 I have often traced the trouble to a bad condition of the teeth, which 
 at the same time causes intoxication by the putrefactive products of 
 dental caries and pyorrhea alveolaris, and favors abnormal gastro- 
 intestinal fermentation through incomplete mastication and insali- 
 vation of the food. Sometimes, an insufficiency of the emunctories 
 is properly held responsible, such as renal, hepatic or intestinal 
 insufficiency, or a deficient function of the organs of internal secre- 
 tion. Whatever may be the pathogenic mechanism, the relation 
 between the dermatosis and these functional anomalies is entirely 
 admisssible. Urinary examinations unfortunately yield no con- 
 cordant results, rendering futile the hope of a coming " urinary 
 formula of eczema." 
 
 Nutritional disturbances, the hereditary influence of which has 
 been referred to, are naturally still more injurious when affecting 
 the patient himself. Sometimes, as the patient is sure to empha- 
 size, an indisputable alternation or substitution is noted between 
 the attacks of eczema and certain symptoms such as asthma, neu- 
 ralgias, migraines, bronchial catarrhs, or digestive disturbances. 
 An obstinate progressive eczema frequently precedes by several 
 months or years, and so to say intimates, the manifestation of a 
 latent visceral cancer. Diabetic patients are evidently predisposed 
 to eczema which not uncommonly begins in the genital regions. 
 
 The part played by nervous disturbances is equally apparent. 
 A predisposition to eczema is created, not by central or peripheral 
 nervous lesions, but rather by neurasthenia, overstrain, emotions, 
 moral shock, grief, etc. We do not know if the nervous system 
 acts through a vasomotor or trophic disturbance, which would 
 already be the first stage of the eczematous process; or if it acts 
 merely by lowering the resistance of the skin. At any rate, it 
 seems to be a, loss of nervous balance which brings about the exces- 
 sive irritability of the eczematous areas which show themselves 
 intolerant toward any active form of medication. 
 
 A reflex nervous action on the skin has been held responsible 
 for the temporary predisposition to attacks of eczema caused by 
 the eruption of teeth, by menstruation, pregnancy, lactation, the 
 menopause, etc. 
 
 Regional circulatory disturbances, like those accompanying vari- 
 cose veins, for example, may create a manifest local predisposition 
 to eczema. 
 
 The pathogenic mechanism according to which these manifold causes 
 net i necessarily extremely variable. To formulate it in a few words, 
 one woul I be tempted to say that as the process is inflammatory; it 
 represents a, defense reaction of the organism against the injurious 
 agents which attack the skin. 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 69 
 
 Although barely admissible for the external causes this general 
 idea would not cover the internal causes. Too many decisive 
 arguments refute the theory, which is still occasionally admitted, 
 however, according to which the skin acts vicariously for other 
 emunctories when these are insufficient, and becomes eczema- 
 tous under the influence of autogenous poisons, toxins and waste 
 products, which seek an outlet through the skin. 
 
 A rather attractive theory was advocated by Jacquet, who 
 claimed the intervention of a nervous reflex action of trophic char- 
 acter. Visceral lesions or internal disturbances are supposed to 
 modify the nervous impulses transmitted to the skin, the resulting 
 trophic change enabling the skin to react in the form of eczema 
 against strong or even very weak external irritants which would 
 have been readily tolerated in the normal state. 
 
 The majority of eczemas undoubtedly result from a combina- 
 tion, in variable proportions, of external and internal factors. It is 
 therefore imperative, in a given case, to ascertain through careful 
 clinical analysis the "etiological dominant" and the accessory 
 causes. Only when this requirement is complied with can a rational 
 treatment be instituted with some prospect of a successful out- 
 come and the prevention of recurrences. 
 
 Symptoms. — When eczema appears suddenly, on a rather exten- 
 sive surface, or during an exacerbation in the course of chronic 
 eczema, certain general symptoms may be noted, such as digestive 
 disturbances and especially malaise, excitement, insomnia, pros- 
 tration and a slight fever. 
 
 The eruption is essentially polymorphous; it consists of redness, 
 vesiculation, exudation, crusts and scales. Its most characteristic 
 feature has very properly been stated to be vesiculation, but 
 certain eczemas run their course without at any time presenting 
 demonstrable vesicles. 
 
 In a general way, but remembering that, as a rule, several stages 
 exist together, the succession of the phenomena may be described 
 as follows: At the onset, vivid reddening with diffuse margins 
 makes its appearance, showing a very finely granular surface on 
 inspection with a lens, with more or less edema, tension and 
 pruritus; representing the erythematous stage. It is rare for the 
 redness to be absent or to escape observation and for the vesicles 
 to appear on healthy skin. The edematous redness sometimes, 
 after persisting for a few hours or a day, fades away and leaves 
 behind a fine lamellar or furfuraceous desquamation, this being 
 observed especially in the face and the genital regions. 
 
 As a rule, a few hours after the onset of the attack, a large crop 
 of very superficial vesicles makes its appearance on the erythem- 
 atous surface, with transparent contents, from the size of a needle- 
 
70 
 
 ECZEMA 
 
 point to that of a pin-head, very close together, sometimes becom- 
 ing confluent in bullae of moderate size; this is the vesicular stage. 
 On the hands and feet, in regions where the epidermis is thick, the 
 vesicles are deeper and have less tendency to rupture. They may 
 dry in crusts which are gradually eliminated. 
 
 Usually the vesicles do not exist long without rupturing spon- 
 taneously or under the influence of scratching and permit the 
 escape of a clear, slightly stringy fluid, faintly yellowish or turbid, 
 stiffening the underwear like mucilage. The exudative stage may 
 be prolonged for several days or even weeks in different cases 
 
 Fig. 8. Ecze 
 
 sts, showing eczema "pores." 
 
 When dressings are employed, the surface of the skin, on removing 
 the dressings, is seen to be red or a vivid pink, smooth and perfor- 
 ated with superficial round or polycyclic erosions from which 
 droplets of a clear sticky serous fluid exude. In case no vesicles 
 have been demonstrable, these erosions which are the eezematous 
 pores previously referred to, represent their equivalent (Fig. 8). 
 
 In the absence of dressings and when the exudate is not very 
 profuse it dries in thin yellowish crusts, or in brown concretions 
 when a little blood is mixed with the serum; constituting the stage 
 of incrustation, or crusted eczema. 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 71 
 
 When a pyococcic infection becomes implanted on the eczematous 
 surface, which is not uncommon in children or in certain regions 
 of the body, the secretion is mixed with pus, the crusts are meli- 
 cerous or grayish, thicker and rougher. The surrounding areas 
 present the features of genuine impetigo and the case becomes one 
 of impetiginous eczema (p. 82). 
 
 The exudate lessens and dries up after a variable time; the 
 crusts fall, the surface becomes covered with epidermis; but the 
 new horny layer remains thin, transparent, slightly adherent; it 
 cracks through desiccation (fissured eczema), and is shed in lamellar 
 or furfuraceous scales which are incessantly renewed. 
 
 This stage of desquamation may last a very long time. The 
 vesicles are very apt to reappear on the pinkish scaly surface, sepa- 
 rately or in groups, continuously or in crops, with a renewal of the 
 the exudation and crust formation. 
 
 The persistence of the eczematous process, aggravated by scratch- 
 ing, the local conditions of the affected region and the general 
 health of the patient, tends to produce a thickening of the patches, 
 with elevation and induration. The normal folds and lines of the 
 skin are more pronounced, the surface is dry and roughened, scaly 
 or crusted. This condition is designated as lichenified eczema. 
 
 Eruptive Varieties. — It is uncommon for the various stages of 
 the eczematous process to follow a regular course; as a rule, they 
 intermingle, blend and exist together in the same patient. How- 
 ever, it must be admitted that certain eczemas, or rather the eczemas 
 of certain patients, preferably assume one or other objective form 
 and persist a long time at one of the stages, the characteristics of 
 which are then especially well marked. 
 
 The varieties of the eruption which require special mention are 
 the following: 
 
 Vesicular eczema, with constantly renewed vesicles, occurs espe- 
 cially on the extremities. A special type has been distinguished 
 under the name of dysidrosis. 
 
 Exudative eczema, with continuous exudation, is observed in 
 gouty or obese persons especially on the legs and arms, in the new- 
 born on the face, sometimes as the result of irritative applications. 
 
 Eczema rubrum is the form in which the reddening is intense 
 (often edematous) and does not completely disappear under 
 pressure of the finger, indicating an abundant diapedesis of red 
 corpuscles in the cutis. It occurs in extensive patches in acute 
 attacks, or is persistent and indolent, on the legs, on the large folds 
 and also in the face. 
 
 The term erysipeloid eczema is sometimes employed to desig- 
 nate sudden inflammatory and edematous attacks, sometimes 
 followed by vesico-bullse, affecting especially the face and the genital 
 
72 ECZEMA 
 
 organs. It is frequently a complication of a dry sluggish eczema, or 
 the result of an artificial local irritation. 
 
 Dry eczema, which in exceptional cases is arranged in circum- 
 scribed spots or patches, often polycyclic, with a pinkish scaly sur- 
 face, without demonstrable vesicles, is so common and so peculiar in 
 its appearance and behavior that there is a strong temptation to 
 place it in a group by itself ( seborrhoeic eczema, seborrheid, psoriati- 
 form parakeratosis, etc.). It will be discussed at length under the 
 name eczematides in the chapter on the erythemato-squamous 
 dermatosis (V, p. 90). 
 
 Squamous eczema, in which desquamation is abundant and con- 
 tinuous, is encountered especially in individuals or regions with 
 defective nutrition. 
 
 Horny, or keratotic or tylotic eczema is practically limited to the 
 plantar and palmar regions (XI, p. 214). 
 
 Lichenified eczema, often circumscribed, very pruriginous and 
 chronic, seems to be likewise connected with special local condi- 
 tions. Its differentiation from eczematized prurigo is sometimes 
 very difficult (p. 489). 
 
 Imjietiginous eczema, more common in children and in the arti- 
 ficial dermatitides may give rise to folliculitis, furuncles, adenitis, 
 lymphangitis and abscesses, in short, to all the manifestations of 
 pyodermatitis (p. 82). 
 
 Varieties of Configuration. — The distribution and extent of ecze- 
 niatous eruptions are extremely variable and not easily classified. 
 The most usual configuration is in form of spots, patches or 
 surface lesions of very unequal size and quite irregular contours, 
 in geographical or archipelagous designs. This type, designated 
 as amorphous eczema by Devergie, is entitled to the name of 
 eczema uulgare. 
 
 The so-called papulo-vesicular eczema of Brocq is characterized 
 by the fact that its initial element is a small papulo-vesicular 
 elevation, instead of a simple vesicle; the confluence of these lesions 
 results in patches with an indurated base. The eruption is gene- 
 rally widely scattered and develops in successive crops. There is 
 intense itching and the relation of this form to the prurigos is very 
 evident in certain cases. Frequently, however, this va r iety is com- 
 bined with eczema vulgare in other regions of the body. 
 
 Nummular eczema assumes the form of round or oval, sharply 
 circumscribed spots, which are sometimes herpetoid (I nna) or 
 trichophytoid (Sabouraud). It is common on the wrists, on the 
 dorsal aspect of the hands and on the legs. [The patches are 
 remarkable for the absence of peripheral extension, their recurrence 
 throughout a number of years and the association of moderate 
 eosinophilia.J 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 
 
 73 
 
 Varicose eczema and paratraumatic eczema of war wounds are 
 noteworthy on account of their distinctly outlined borders, their 
 
 Fig. 9. — Paratraumatic eczema, following on a bullet-wound of the right arm 
 of three months' standing, cured in fifteen days. Noteworthy case on account of the 
 arciform and syphiloid configuration of the eruption. Note the central cicatrization 
 and the extension by vesico-pustules, especially on the convexity of the border at the 
 base of the figure. 
 
 Fig. 10. — Eczema of the papulo-vesicular type on the forearm. 
 
 usually polycyclic configuration, and their continuous peripheral 
 extension; they are apt to be combined with impetigo. 
 
"4 
 
 ECZEMA 
 
 The eczema marginatum of Hebra is a parasitic epidermatitis due 
 to the epidermophyton (p. 52 ! i. 
 
 Disseminati ■ eczema will he considered in a paragraph 
 
 by itself (p. s 7 . 
 ' Generalized eczema will be discussed with the erythrodermas 
 ,,. 120 and eczema foUicuhriim in the chapter on the folliculoses 
 
 ged six years 
 
 Regional Varieties. On the scalp, especially in children, eczema 
 is often incited by pediculi and associated with pyodermatitis; in 
 youthful individuals and in adults it is ordinarily a, complication 
 of pityriasis and there are imperceptible transitions between dry 
 pityriasis, steatoid pityriasis, dry, exudative and crusted eczema 
 (see Kerosis, p. 196). 
 
 In the beard and hairy regions the same relations with pityriasis 
 are noted. The eczema may be of the exudative type and often 
 gh es i ise t" p> ococcic \\ cosis. 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 75 
 
 Orbicular or orificial eczemas are dry or exudative, often very 
 obstinate and are caused or maintained by lesions of the mucous 
 membranes and corresponding cavities; they have been interpreted 
 as of reflex origin. On the lips, a bad condition of the teeth, irri- 
 tating tooth-pastes, pharyngitis, etc., may be responsible. 
 
 Persistent desquamation of the red border of the lips forms a special 
 type of unknown character which has been referred by some writers 
 to psoriasis, seborrhea, etc. 
 
 On the nostrils, eye-lids and ears conditions are involved such 
 as chronic coryza, sinusitis, ocular disturbances and otitis media 
 or externa; in eczema of the vulva, the trouble may be due to 
 diabetes, cystitis, vaginitis, or metritis; in eczema of the anus, to 
 hemorrhoids, fissures or constipation. 
 
 Perigenital and peri-anal eczema very frequently follow on 
 pruritus of these regions. 
 
 Generalized eczema of the face, extending to the neck and thorax, 
 is often incited in adults by dyes for the hair and beard, or is the 
 result of an occupational dermatitis. In children it is often recur- 
 rent and related to digestive disturbances or the eruption of teeth. 
 
 Eczema affecting the nipple and areola, in women, is often 
 weeping, limited, very obstinate and almost exclusively produced 
 by scabies (Fig. 150), or pregnancy and lactation. It must be 
 carefully differentiated from Paget's disease of the nipple. 
 
 Eczema of the large folds localized in the articular, submammary, 
 subabdominal and intergluteal folds, etc;, is not uncommon in 
 obese, diabetic or gouty subjects; it is exudative and diffuse, or 
 dry and marginate. 
 
 Intertrigo eczema of infants (p. 31) represents a higher degree of 
 irritative reaction than simple intertrigo erythema. 
 
 On the legs, eczema is observed very frequently and in all its 
 forms; it is associated with varicose veins, traumatic lesions, ulcers, 
 etc., and leads secondarily to dermatoscleroses and hypertrophies. 
 
 On the hands, tvrists and forearms the majority of eczemas are 
 caused by external occupational toxidermias; further on I shall 
 discuss dysidrosis, which affects also the feet. 
 
 Between the toes, it is common to find a red pruritic dermatitis, 
 with exfoliation of large macerated horny shreds. This form has 
 been grouped under eczema, dysidrosis or intertrigo by different 
 writers; Sabouraud has shown that it is usually parasitic and due to 
 the epidermophyton inguinale. 
 
 The question of eczema of the mucous membranes is a mooted 
 one. Undoubtedly, eczema exists on the semimucosa?, the red 
 border of the lips, glans penis, labia majora and minora. But in 
 the mouth, on the tongue, in the nasal fossae, on the conjunctivae 
 and in the vagina, the reactions caused by eczematogenic factors 
 
76 ECZEMA 
 
 are clinically and histologically different from those noted in the 
 skin. 
 
 Course and Prognosis. — The course of eczema in general is extremely 
 variable. Authors recognize an acute and a chronic eczema, accord- 
 ing as the eruption appears abruptly and subsides in a few weeks, or 
 becomes locally established and recurs during a period of months 
 or years. This distinction is arbitrary and useless. 
 
 The prognosis of a given eczema depends in part on its cause 
 and in part on the patient's state of health, namely the degree of 
 predisposition present; the latter is often recognized only a 
 posteriori. 
 
 In a general way, it may be stated that it is the nature of eczema 
 to advance in attacks or relays (e/cfeyuo:, ent;eiv, to boil over or 
 effervesce). Eczema begins most frequently but not always with 
 a sudden hyperemic attack with general malaise in its course; it is 
 the rule that new paroxysms and rapid extensions occur at variable 
 intervals, readily provoked by external or internal disturbances. 
 Tins "tendency to react toward irritants by an increased exuda- 
 tion and inflammation" is so characteristic that Unna included it 
 in his definition of eczema. 
 
 During the intervals of the attacks there may be progressive 
 improvement, or simple persistence, or progressive aggravation; or 
 pyodermic, lymphangitic, etc., complications may make their 
 appearance. 
 
 Eczema may constitute a real infirmity, preventing employment 
 in a number of occupations. The pruritus and desparation caused 
 by it have sometimes resulted in cachexia or even led to suicide. 
 Fatal cases for which eczema has been held responsible, are probably 
 referable to visceral diseases of which the eruption was merely one 
 manifestation (see Kczematosis). 
 
 Diagnosis. It would be an endless task to point out all possible 
 errors. I snally, moreover, the diagnosis of eczema is clear, through 
 the demonstration of a polymorphous epidermodermatitis, assum- 
 ing one or several of the above described clinical aspects and 
 arranged in spots or patches with irregular margins. Vesicles 
 should not be credited with a greater diagnostic value than the other 
 elementary constituents, the process as a whole being the charac- 
 teristic feature of the disease. 
 
 Greater difficulties arise in elucidating the cause and origin of the 
 eczema. The points to be determined are these: Is the eczema 
 purely external and, as it were, traumatic; is it primary, originating 
 in the healthy skin, or secondary to a preceding dermatosis; what 
 is the part played by predisposition, local or visceral affections or 
 the general condition of the patient? The beginner's task will be 
 facilitated to some extent, I hope, by the comments which follow 
 on some of the principal types. 
 
ECZEMA, ECZEMATIZATION, ECZEMATOSIS 77 
 
 Treatment. — Limitation is imperative in a field of such magnitude, 
 so that only a few brief practical directions will be presented. 
 
 All cases of eczema should be treated because the patient is 
 uncomfortable and is threatened with the danger of the eruptions, 
 extending as well as becoming infected. The dread of internal 
 "repercussions" is largely imaginary; although experience has 
 shown that in very extensive eczemas, in those due to grave organic 
 or nutritional changes, or which show evidence of vicarious or 
 substitution phenomena mentioned above, it is advisable to apply 
 only clean dressings or very mild soothing lotions and to avoid all 
 active medication. 
 
 Two important rules are as follows : In every case of eczema, the 
 physician must in the first place analyze the probable causes of the 
 eruption, systematically and with strict attention to detail. To 
 begin with, external irritants are looked for and eliminated as far 
 as possible; next, preexisting dermatoses, with their marked bear- 
 ing on the prognosis and treatment and finally, internal causes, 
 which should be controlled by means of appropriate measures. 
 
 The second, equally important rule is that the treatment of 
 eczema must be symptomatic and flexible, rather than systematic 
 and predetermined. By this statement is meant that the erup- 
 tion should be treated according to its behavior, instead of blindly 
 applying one or other formula or medication of " anti-eczematous" 
 repute. 
 
 Local Treatment. — Acute eczematous attacks require complete 
 rest, or at least rest of the affected region, with a prescription of 
 simple lotions or spraying with vegetable infusions, or very mild 
 antiseptic solutions and generous applications of neutral powders 
 which favor desiccation; these can be alternated with cooling 
 creams. Salves and pastes are all objectionable at the beginning 
 of an acute attack, as they have a tendency to "heat" the skin 
 and to macerate the epidermis. 
 
 In the presence of a crusted or impetiginous eczema, the crusts 
 should always be removed in the first place and this is accomplished 
 by means of lotions with a vegetable or astringent decoction, 
 such as very dilute Alibour water (see Therapeutic Notes § 2), or 
 the application of dusting powders, preceded if necessary by moist 
 dressings [with Liq. aluminis acetatis, 1 : water 10] or aseptic 
 softening poultices. When the surface is clean and the inflammation 
 has subsided, treatment is begun, while continuing the use of lotions 
 twice daily — with applications of ichthyol pastes, with a small 
 addition of resorcin or yellow oxide of mercury pastes; sometimes 
 bland powders, glycerol of starch or watery pastes prove useful. 
 
 In cases of oozing and itching eczema, painting with an aqueous 
 solution of silver nitrate (1 : 10 to 1 : 30) repeated every two or 
 threeMays, is*sometimes effective. 
 
78 ECZEMA 
 
 When the eczema is only slightly inflammatory, without exu- 
 dation, but squamous or lichenoid, treatment may begin — after 
 thorough cleaning with vaseline or as is my custom, with petroleum 
 ether — with the series of pastes, then ointments, made with tar, 
 sulphur, weak or strong reducing agents, mercurials, etc., starting 
 with the weakest and passing up to pure tar, topical applications of 
 chrysarobin or pyrogallol and compound plasters. In case an 
 excessive reaction follows, milder measures should be temporarily 
 resumed. The most experienced dermatologists usually employ 
 strong topical applications very guardedly . The recommendation 
 to make use of only the simplest and best tried remedies cannot be 
 overemphasized. 
 
 The treatment of dry, psoriatiform and hyperkeratotic eczemas, 
 and of pruriginous eczemas, is the same as that of other dermatoses 
 presenting the same characters. 
 
 Mention must finally be made of a few topical applications of 
 more exceptional employment, which sometimes yield very favor- 
 able results. 
 
 Continuous and direct applications of caoutchouc, or better of 
 caoutchouc-covered cloths, have enjoyed a considerable vogue, 
 but they are often badly tolerated and it is difficult to determine 
 just when their employment should cease. 
 
 Contrary to what might be expected strong compound ointments, 
 such as those [of tar and sulphur or even tar and chrysarobin] of 
 the type of Baissade's balsam (Therapeutic Notes, § 7) [or Dreuw's 
 ointment] are efficient not only in the obstinate forms, but also in 
 tin case of acute and weeping eczema. Dind (of Lausanne) has 
 shown that crude washed coal tar can be employed under the same 
 conditions; painted on, then dusted with talcum powder, it forms 
 on drying a coating which is left in place for three to eight days; 
 this inexpensive, convenient and highly keratoplastic agent has been 
 generally adopted and has rendered excellent service. 
 
 The indications for electrotherapy in the form of static baths or 
 high-frequency currents are imperfectly understood. These pro- 
 cedures are less valuable than radiotherapy, which possesses a high 
 degree of efficiency in very pruriginous and lichenoid eczemas as 
 well as in the eczemati/.ed prurigos. However, it is resorted to 
 only exceptionally in localized and very obstinate cases. [The 
 .T-rays are valuable in all forms of eczema except the acute, not 
 only for their antipruritic effect but also for their action on the 
 infilt rations.] 
 
 (lateral Media/linn.- There is no specific for eczema, but in 
 nearly all these patients, it is necessary to intervene for the regu- 
 lation of hygienic conditions and the control of the existing tendency 
 to nutritional or visceral disturbances, if any such be disclosed. 
 
ARTIFICIAL ECZEMAS 79 
 
 The diet, restricted in quality as well as quantity, should be that 
 of the congestive and pruriginous dermatoses of autotoxic origin. 
 A vegetable or milk diet is sometimes necessary. 
 
 Constipation and digestive disturbances must be carefully 
 regulated. It is sometimes essential to train the patients to eat 
 slowly and chew their food well (bradyphagia) ; it may be necessary 
 to insist on the services of a competent dentist for the repair of 
 teeth or the fitting of dental plates. 
 
 General hygiene, a quiet life, physical, mental and moral rest 
 and sojourn in the open air, if possible, are of course very desirable. 
 
 As to internal medicinal treatment, this varies in different cases 
 and may consist in the prescription of alkalis, cod-liver oil, calcium 
 salts, phosphates or phosphoric acid, iron or arsenic; exceptionally, 
 in opotherapeutic remedies (such as thyroid, suprarenal, hepatic, 
 ovarian, intestinal extracts, etc.). 
 
 Arsenic medication, formerly considered indispensable in every 
 case of eczema, has greatly fallen in repute and as a matter of fact, 
 arsenic is more apt to be injurious than useful, especially in the 
 acute forms. As a tonic it may be advantageously employed in 
 sluggish eczemas and in weakened nervous patients. I agree with 
 the majority of dermatologists, in preferring the sodium arsenite 
 to the cacodylates, methyl arsenites or analogous preparations. 
 
 It is difficult to state in a few words what mineral waters are 
 suitable for eczematous patients. In a general way, the lymphatic 
 group may be referred to sulphur springs; the gouty to alkaline 
 and silicate springs; nervous irritable persons are benefited by 
 waters charged with calcium sulphates; nervous patients suffering 
 from auto-intoxication do well on so-called neutral and sedative 
 waters; long-standing cases of the dry and lichenoid type may 
 employ arsenical waters. 
 
 Some of the most frequent clinical types of eczema are entitled to 
 a special discussion: 
 
 ARTIFICIAL ECZEMAS. 
 
 Their special features depend upon their cause, localization and 
 evolution. 
 
 The irritants most apt to incite an eczematous reaction and the 
 occupations which most often lead to its occurrence are discussed 
 in the chapter on the artificial dermatitides (pp. 463, 467). 
 
 The artificial eczemas naturally develop first of all in the regions 
 directly exposed; on the hands, especially in the interdigital folds, 
 on the wrists and forearms, in cases of occupational eczema (see 
 Figs. 8 and 144) ; on the face and neck, in dermatitis due to dyes, etc. 
 
SO ECZEMA 
 
 They have a tendency to spread by peripheral extension, but 
 may also advance in leaps, reaching, for instance, the face, the neck, 
 the thighs or the genital regions. 
 
 Several explanations of these transferences have been sug- 
 gested. The injurious substance was assumed to have been trans- 
 ported, for example, by the patient's fingers, which is possible in 
 certain cases; or the toxic agent was believed to have undergone 
 absorption, manifesting it^ effect from within outward, in predis- 
 posed regions; again, the eruption at a distance was interpreted as 
 the result of a reflex action, although it is hardly likely for a true 
 inflammation to be the result of a purely nervous pathogenesis. 
 The most plausible explanation, in my opinion, is that which 
 regards the [reflex] diffusion of the pruritus as the predisposing 
 cause and the scratching or the transportation of the microbic 
 invaders of the first eczematous focus, as the determining cause. 
 
 The artificial eczemas are often distinctly vesicular from the 
 start; or they may be erythemato-edematous or even erysipelatoid, 
 quite at the beginning, becoming vesicular secondarily. They are 
 very commonly infected by pyococci and become impetiginous in 
 places, while elsewhere they become keratotic, present fissures and 
 cracks, become covered with crusts and assume a nummular or 
 lichenoid appearance. Extraordinarily polymorphous but never- 
 theless characteristic appearances are the result, such as those to 
 which special names like grocers' itch, bricklayers' and cement- 
 workers' itch, etc., have been given. 
 
 Sometimes, sublata causa, a cure follows with the greatest 
 rapidity and almost without treatment; cases of this kind are 
 described as traumatic eczematiform dermatitides. However, all 
 intermediary degrees occur between this contingency and that of 
 prolonged persistence, with recrudescence without apparent cause 
 and with invasion of and establishment in remote areas, represent- 
 ing a true eczema, originating from a focus of local irritation. 
 
 Even when a more <>r less rapid cure is obtained, the patient 
 remains predisposed to recurrences under the influence of the same 
 cause in- analogous causes through the effect of a sensitization 
 which has been compared with anaphylaxis; and a change of 
 occupation may become imperative. 
 
 INFANTILE ECZEMAS. 
 
 In lii tic children, especially between the second to the eighth 
 month, eczemas of rather peculiar etiology, topography and evolu- 
 tion arc observed with great frequency 'in 5 or 10 per cent, of 
 children in Paris). These children are apt to have eczematous, 
 neuropathic, intemperate or overworked parents. Their diet, 
 
SECONDARY ECZEMATIZATION 81 
 
 whether they are breast-fed or raised by hand, in the presence or 
 absence of evident digestive disturbances, may be injurious by its 
 quality, its too frequent repetition and especially, as has been 
 shown by Marfan, through an oversupply of food. It must be 
 watched and regulated according to the requirements in a given 
 case. Weaning, when carefully managed, is not particularly 
 dangerous in infantile eczemas and may on the contrary lead to a 
 cure. The part played by the eruption of the teeth, although it 
 has been exaggerated, is evident in many cases; it acts by the con- 
 gestions, nervous condition and digestive disturbances with which 
 it is associated. Various local causes, bad hygiene of the skin, an 
 excessive use of soap, coryza, impetigo, vaccination, etc., may all 
 serve as determining factors. 
 
 Infantile eczema affects preferably the face, especially the cheeks, 
 the forehead and the lips, while the nose and chin often escape. 
 Sometimes it begins on the healthy skin in a distinctly vesicular 
 form, followed by oozing; in other cases it originates in the sebace- 
 ous ducts of the scalp and forehead, where it is known as "milk- 
 crust," forming a continuous series from pityriasis simplex to dry, 
 impetiginous, or even exudative and crusted eczema; sometimes 
 again, although the two preceding forms are likewise, as a rule, 
 accompanied by erosions, the eruption is obviously secondary to a 
 primary localized pruritus and to the scratching provoked by it. 
 
 This eczema may remain localized, or it may extend as far as the 
 buttocks, the limbs and the trunk. The general condition often 
 remains excellent and the eruption usually stops and disappears 
 about the middle or end of the second year. 
 
 Its etiology, localization and course differentiate true infantile 
 eczema from eczematiform dermatitis, usually sta r ting from the 
 buttocks, which has been referred to above; the latter represents 
 merely an advanced degree of intertrigo-erythema and is entitled 
 to the designation of intertrigo-eczema. 
 
 SECONDARY ECZEMATIZATION. 
 
 Eczematization which develops on the soil of other dermatoses 
 and is provoked by the same, seems to be the cause of much con- 
 fusion in the classical picture of eczema. Familiarity with this 
 mode of origin of eczema which depends on the so-called pre- 
 eczematous dermatoses is of the greatest practical importance for 
 the clinician as in a large number of cases it enables the clinician 
 to make a correct diagnosis and prognosis and to institute pre- 
 ventive treatment. Moreover, on the assumption that eczema is 
 merely a mode of cutaneous reaction, the theoretical explanation 
 of these facts meets with no insurmountable difficulties. 
 
82 ECZEMA 
 
 Eczema and Impetigo. The relations of impetigo to eczema are 
 complex and have given rise to various interpretations. Clinical 
 findings are rendered intelligible on the basis of the following 
 considerations : 
 
 Impetigo or superficial pyoeoccic infection of the epidermis is 
 very frequently grafted on an existing eczema, whatever its origin, 
 external and artificial or internal and constitutional. The result is 
 a modification of the clinical aspect of the eczema, the secretion 
 becoming purulent and the crusts melicerous and coarse, consti- 
 tuting impetiginized eczema. The neighboring lesions or auto- 
 inoculations, the result of scratching, may be the lesions of eczema 
 or the pustules of impetigo, or a mixture of the two. 
 
 Conversely, impetigo may give rise to eczema, in this sense that 
 the pyoeoccic agents of impetigo under certain conditions (prob- 
 ably when they possess a high degree of virulence) and in certain 
 regions, are capable of giving rise to epidermodermatitis of the 
 eczematous type like other irritants. This microbic eczema, 
 which might be called impetiginous eczema, unlike impetiginized 
 eczema, lacks constant characteristics and I believe it may assume 
 the aspect of a vesicular or oozing, crusted or squamous eczema, or 
 even that of dry eczema. The investigations of Sabouraud have 
 even led to the conclusion that pityriasis simplex may be regarded 
 as a "dry impetigo." 
 
 This second proposition will hardly be admitted offhand ; although 
 it is based upon a number of histological and bacteriological exami- 
 nations carried out in my laboratory with careful analysis of clinical 
 cases and is, I believe, in harmony with the existing facts. 
 
 Eczema and Kerosis. The pathological conditions of the epidermis 
 known as pityriasis and seborrhea, grouped by me under the heading 
 kerosis (p. 196), create a territory peculiarly predisposed to eczema- 
 tization. Most commonly, an eczematide or dry eczema develops 
 under these conditions, but this dry eczema has a marked tendency 
 to react in the form of exudation and extensive inflammation under 
 the influence of scratching, injudicious treatment, or other local 
 and general causes; constituting the eczematized seborrheic! of some 
 authors. 
 
 Vesicular, oozing, crusted, impetiginous eczema may likewise 
 become established from the start in cases of kerosis. The sites 
 of predilection of kerosis, primarily the hairy scalp, the face and the 
 large articular folds, are naturally also the usual starting-points of 
 these eczemas. 
 
 The kerotic origin of eczema is so common that according to 
 I'nna, the great majority of eczemas would be suppressed by 
 treating and curing seborrheal eczema in its early stages. 
 
ECZEMATOSIS 83 
 
 Eczema and Prurigo. — Pruritus and prurigo, diffuse or localized, 
 of variable origin, are conditions very apt to become eczematized 
 and the starting-point of more or less extensive and generalized 
 eczemas. Scratching, through its mechanical action and the 
 resulting microbic inoculation, constitutes the pathogenic factor 
 in this complication, which is met with in the urticarias and in 
 scabies. However, not all scratched prurigos become eczematized, 
 but have rather a tendency to lichenize, indicating that a certain 
 degree of local or general predisposition is necessary. 
 
 It must not be overlooked, on the other hand, that primary 
 eczema is itself pruriginous and becomes lichenized under certain 
 conditions of persistence, localization and soil. The relations of 
 eczema with the pruriginous dermatitides are accordingly complex, 
 the particular cases requiring careful analysis. 
 
 Aside from these three conditions in which eczematization is 
 extremely common, a long list of dermatoses should be men- 
 tioned which, although less frequently, may become complicated 
 by eczema. 
 
 Mycosis Fungoides. — Mycosis fungoides includes patches of lichen- 
 oid eczema among its common initial symptoms. The exfoliating 
 erythrodermas are often eczematized, especially in the folds. The 
 ichthyoses and hyperkeratoses are likewise subject to eczematiza- 
 tion. Hyperidrosis and intertrigo-erythema mustalso be mentioned 
 among the pre-eczematous dermatoses. 
 
 ECZEMATOSIS. 
 
 Under this name I designate the chronic, constitutional or 
 dyscratic disease, in which the eczema eruption is the principal 
 manifestation and which is generally designated under the name of 
 true eczema or eczema disease. 
 
 Eczematosis is met with at all ages. Certain eczemas of new- 
 born infants belong under this heading; in the course of childhood, 
 adolescence and youth, it seems to be an attribute of lymphatic, 
 anemic or scrofulous individuals; at the age of maturity, it affects 
 the overworked, inebriate and intemperate, the wealthy class being 
 more susceptible than hospital and dispensary patients. It is 
 especially common in arteriosclerotic and senile individuals where 
 it becomes a very distressing and often almost incurable infirmity. 
 I have often been put on the track of a latent visceral cancer or a 
 partial retention of urine, pyelonephritis, etc., by incessant rebel- 
 lious attacks of eczema in an aged man. 
 
 In a general way, the etiology of eczematosis is characterized 
 by the fact that the local or external causes play a rather un- 
 important part, whereas the so-called internal causes together 
 
84 ECZEMA 
 
 with ;i predisposition of organic or humoral origin occupy the 
 first rank. In the presence of eczematosis, visceral lesions and 
 chronic intoxications are often demonstrable to such a degree 
 that it is difficult to determine the precise cause. In other cases, 
 the behavior suggests a sensitization of the patient through mul- 
 tiple or polyvalent antigens, rendering him susceptible to slight or 
 even inappreciable causes. 
 
 Almost invariably, however, the onset of the eczematosis can 
 be referred to a cutaneous traumatism, an accidental local irrita- 
 tion, repeated scratching induced by anal or genital pruritus, 
 inflamed varicose veins, etc. Or it may take its origin in a pro- 
 tracted pityriasis of the scalp, or in an old patch of dry eczema. 
 Finally, it is seen to occur, as if through the effect of a "metas- 
 tasis" or substitution, at the time of spontaneous or artificial 
 suppression of asthma, bronchial catarrh, enteritis, neuralgia or 
 rheumatic pains. 
 
 Finally, the most trifling causes, the mildest applications, wash- 
 ing with soap, fatty substances and even water may provoke attacks. 
 The skin of persons having constitutional eczema seems to have 
 become less capable of adjusting itself to external conditions and 
 they are attacked by paroxysms on occasions such as a change of 
 temperature, season, climate, or humidity of the air, on exposure 
 to wind, etc.; briefly, any condition which modifies the state of the 
 cutaneous circulation and secretion. 
 
 The clinical picture of eczematosis need not detain us. It will 
 suffice to state that the eruption may assume any form and degree, 
 and affect any region, as discussed under eczema in general. The 
 pruritus is variable in degree, often intolerable, paroxysmal and 
 especially nocturnal, contributing on the one hand to the main- 
 tenance of the lesions through the scratching caused by it and on 
 the other to the depression of the nervous system and the morale 
 of the patient. 
 
 Notwithstanding intelligent and scrupulous treatment, a cure 
 cannot always be obtained, or it is only temporary and followed by 
 recurrences. It is very common for these recurrences or renewed 
 attacks to start from an imperfectly extinct focus, a focus of microbic 
 growth according to the adherents of the parasitic theory of all 
 eczemas. The disease lasts years and sometimes till death, w r hich 
 may occur in consequence of the organic lesions back of the erup- 
 tion, such as Bright's disease, arteriosclerosis, chronic bronchitis, 
 cancer, diabetes, etc. 
 
 It frequently happens that the eczema disappears at the moment 
 where the terminal complications supervene, and quite naturally 
 so, because the exhausted organism is no longer capable of respond- 
 ing with a cutaneous reaction. The fact is generally interpreted 
 
DYSIDROSIS 
 
 85 
 
 by the laity and by a number of physicians as indicating a reper- 
 cussion, a "striking in" of the eruption, the effect being mistaken 
 for the cause. 
 
 DYSIDROSIS. 
 
 Under this name, proposed by Tilbury Fox, is designated an 
 affection (named cheiropompholyx by Hutchinson) which is gen- 
 erally regarded as a special disease, but which to me seems to be 
 simply a clinical form of eczema, characterized by certain shades 
 in the behavior of the eruption, by its seat and by its course. 
 
 Fig. 12. — Occupational eczema of the dysidrotic types in a hair-dresser aged 
 twenty-eight years. 
 
 Dysidrosis is seen especially in the spring, from March to June, 
 sometimes in the fall. It recurs in a given case frequently at the 
 same time of the year. Patients suffering from it are adults, 
 rarely children; they present some of the disturbances referable to 
 arthritism; frequently they are dyspeptic, nervous or overworked 
 and perspire very readily. The attack may be caused by violent 
 exercise or by an emotional disturbance. 
 
 The eruption begins symmetrically on the hands or feet, or all 
 four extremities at once; it consists of small or medium-sized vesicles. 
 
86 ECZEMA 
 
 deeply set in the thick epidermis, appearing without redness but 
 with sensations of pruritus, heat, or pain on pressure, sometimes 
 very distressing. 
 
 It assumes its most typical aspect on the lateral surfaces of the 
 fingers, where the skin is white or pinkish and studded with vesicles 
 as if with grains of boiled sago. The vesicles may attain the size 
 of a lentil and become confluent in bullae of the dimensions of an 
 almond or larger, especially on the palms and the soles. A clear, 
 very stringy, neutral or alkaline fluid escapes on puncture; the 
 fluid is sometimes turbid and on the soles is usually purulent. 
 The vesicles of dysidrosis have not much tendency to open spon- 
 taneously and usually dry up in a few days, the epidermis becomes 
 exfoliated and is shed, disclosing a smooth pinkish surface which 
 does not ooze. The course of an attack lasts from five to twenty 
 days. 
 
 The eruption may become infected, impetiginous, especially on 
 the feet and give rise to fissures, lymphangitis, etc. It is usually 
 symmetrical. It may invade the forearms, the neck, the face, a 
 considerable portion of the trunk, or even become generalized when 
 it represents what has been called a dysidrotic eczema. 
 
 The pathological anatomy of the vesicles of dysidrosis shows 
 round or oval cavities, hollowed out at different levels of the 
 rete. Originating in the process of spongiosis, they are filled with 
 a moderate leukocytic fluid which causes a pressure condensation 
 of the neighboring epithelial cells. They have no relation to the 
 sweat channels. The special bacillus reported by I una has not 
 been found by others. Briefly, there are no anatomical reasons for 
 considering dysidrosis as a special dermatosis. 
 
 Clinical arguments are of no greater value. Artificial eczema, 
 when it affects the same localizations or any region with a thick 
 horny layer, presents an identical aspect. Generalized dysidrotic 
 eczema differs in no way from an ordinary eczema. Nothing 
 definite is known as to the causes of seasonal recurrences, which 
 are, moreover, inconstant or very irregular. Having excluded, in 
 the case of the hands, artificial eczemas caused by turpentine, 
 iodoform, poisonous plants or other irritants; at the feet, conditions 
 like epidermophytosis of the toes and ordinary eczema, no cases 
 are left entitled to the label of dysidrosis. It is therefore my 
 belief, shared by .Jadassohn, that this affection is not truly auton- 
 omous. According to Kaufmann-Wolf (1914), about one-third of 
 the cases somewhat generally labelled as dysidrosis are of a tricho- 
 phytic or epidermophytic character. 
 
 There is a desquamation of the hands and feet, a recurrent and 
 often seasonal affection, which is referred to dysidrosis in which the 
 epidermis dries and becomes detached at scattered points or over 
 
DISSEMINATED ECZEMA OR MILIARY IMPETIGO 
 
 87 
 
 polycylic surfaces. In my opinion this is connected with general 
 nutritional disturbances, auto-intoxications, or latent infections, such 
 as chronic appendicitis, dyspepsias, pyelonephritis, etc. 
 
 It is almost superfluous to state that dysidrosis has nothing in 
 common with sudamina, or intracorneal vesicles observed on the 
 trunk and limbs in cases of fever with profuse sweating; nor with 
 hydrocystoma or intradermic cysts, due to dilatation of the sweat 
 channels. 
 
 ACUTE DISSEMINATED ECZEMA OR MILIARY IMPETIGO. 
 
 Under this title I describe a clinical type comprising the erup- 
 tions which have been named acute disseminated morococcal 
 eczema (Unna); miliaria rubra or alba; sudoral eruptions (prickly 
 heat, lichen tropicus, etc.). 
 
 Fig. 13. — Miliary impetigo of the back, following profuse perspiration. 
 
 It is possible that this type corresponds to several distinct patho- 
 logical entities; at the present time they are inseparable. 
 
 The symptomatology is as follows: In a young adult usually 
 of the male sex, one notes the appearance, after profuse sweats 
 caused by a rise of temperature, a steam-bath, hard work, or 
 after cutaneous irritation such as a sulphur bath, of an acute 
 
88 ECZEMA 
 
 eruption of red spots, the size of a pin-head, having for their center a 
 minute vesicle with turbid contents. There is no induration of 
 the lesions, no papular elevation as in eczema of the papulovesicular 
 type of Brocq; nor is the eruption follicular. It occurs especially 
 on the trunk or the first segments of the limbs. The pruritus is 
 variable, sometimes quitesevere. 
 
 Often, but not always, the previous existence of impetigo, impe- 
 tiginized or common eczema, furuncles or a suppurating wound, 
 can be demonstrated in these patients. 
 
 The course is rapid and under proper care the skin not infre- 
 quently clears up in three or four days. Successive attacks may 
 also occur. Sometimes, especially in irritated or scratched regions 
 one or more foci of ordinary or impetiginous eczema form. 
 
 Histology shows, at a point of congestive and edematous derma- 
 titis, a minute blister of the impetigo type (that is, produced by 
 cleavage), or of the eczema type (that is, through spongiosis), w T ith 
 serous contents more or less rich in polynuclears; sometimes there 
 is a combination or a succession of these two processes. It is com- 
 mon, but not constant, for the little vesicle to have a sw T eat channel 
 for its center, although it does not originate through dilatation of 
 one of the canals. A follicular location is unusual. 
 
 Investigations carried out in my laboratory go to show that 
 various staphylococci may be found in the lesions, in different cases, 
 especially citreus and albus; these are the morococci of Unna. 
 
 In my opinion this is a microbic auto-inoculation, scattered in 
 consequence of the maceration of the epidermis by the sweat. 
 
 It win ild be logical to classify this eruption with the impetigos 
 on account of its pathogenesis and evolution, rather than with 
 eczema, since its lesions are not agglomerated and have no tendency 
 to oozing. I am considering it here only because objectively it 
 resembles eczema and has no resemblance at all to ordinary impetigo. 
 
 Very simple treatment w 7 ith non-irritating washes and applications 
 of bland powders or watery pastes, suffices for a cure. Preexisting 
 suppurations should be treated if necessary, and some rest should 
 be recommended. 
 
CHAPTER V. 
 ERYTHEMATO-SQUAMOUS DERMATOSES. 
 
 There exists a group of dermatoses characterized by red and 
 scaling spots. It might be supposed that the eruptive lesions 
 designated by these few words are very common, but this is not the 
 case provided the terms be used in a strict sense. The word "spots" 
 is here employed in its widest application; by their large dimensions, 
 the spots under consideration may be entitled to the name of patches 
 or plaques. The redness must be of a congestive, erythematous 
 character, disappearing momentarily under pressure of the finger; 
 it is circumscribed, limited to the spots and not diffuse. Desquama- 
 tion is present from the start and in all cases it is of the powdery 
 furfuraceous type though sometimes micaceous or scaly and prac- 
 tically always connected with the modified keratinization known as 
 parakeratosis. 
 
 This definition accordingly excludes: (1) Red spots which are not 
 squamous or only become so later on; these belong to the erythemas 
 (I) ; (2) Squamous spots which are not red and which belong to the 
 keratoses (XI) ; (3) Generalized or very extensive reddening, which 
 is known as erythroderma (VI). 
 
 When the spots are small and manifestly surround the hair follicles, 
 I consider them as folliculoses (XIX). 
 
 Erythemato-squamous spots may be secondary to a great variety 
 of eruptions, of erythematous, eczematous, vesicular, pustular or 
 bullous type; representing, not a genuine eruption, but old and 
 deformed lesions about to become macula? (XVI, p. 322). 
 
 I shall here discuss only syndromes of primary erythemato-squam- 
 ous eruptions which originate and persist under this form. 
 
 Such are: (1) The eczematides; (2) pityriasis rosea; (3) psoriasis 
 and (4) the parapsoriases; to which will be added a few words or 
 (5) the psoriatiform syphilides, and on (6) certain epidermomycoses. 
 
 This does not, however, exhaust the list of cutaneous affections 
 capable of presenting the same eruptive type. As a matter of fact, 
 it may be met with, under special features, in certain varieties of 
 lupus erythematodes (XXVII, p. 568) and the tuberculides which 
 approach it more or less closely; in leprosy (XXVII, p. 578) and in 
 mycosis fungoides (XXIX, p. 657). 
 
'." i ERYTHEMATO-SQUAMOUS DERMATOSES 
 
 The reader is referred to the corresponding chapters on these 
 diseases, which are omitted here in the interest of a more complete 
 description. For analogous reasons, the red and squamous spots 
 of the palmar and plantar regions, as well as those of the mucous 
 membranes, are discussed in the chapter on the Keratoses (XI). 
 
 ECZEMATIDES. 
 
 I propose the name of eczematides, to designate the group of 
 erythemato-squamous dermatoses in spots or circumscribed patches, 
 commonly called seborrheal eczemas, seborrhoids, or dry eczemas. 
 
 Different authors consider them as related to pityriasis and 
 psoriasis or as a type by themselves. 
 
 The relations of these eruptions with seborrhea are inconstant. 
 I believe them to be closely akin to eczema, for two reasons: because 
 of the clinical observation of imperceptible transitions and because 
 histologically the lesions are practically identical. However, they 
 cannot be simply incorporated with eczema, for the reason that the 
 lesions differ clinically from the latter by the four following proper- 
 ties: their usual dryness; the sharpness of their rounded or poly cyclic 
 outlines; their very prolonged persistence under the same aspect; 
 their very ready curability under the influence of local treatment. 
 
 The name 1 have selected seems to me convenient, indicating the 
 affinities and suggesting the special characteristics of these eruptions. 
 
 Synonyms and Historical Data. — In view of their great frequency, 
 the eczematides have always attracted the attention of dermatol- 
 ogists. They have borne very many names, which prove the 
 difficulties encountered in their classification: lichen circumscriptum 
 (Willan and Bateman); lichen gyratus (Cazenave and Biett); lichen 
 annulatus serpiginosus (E. Wilson); eczema acneiforme and pityriasis 
 circinata I Bazin); it is the dry, circinate eczema figuration or "flannel 
 eczema" of the dermatologist of the Saint Louis Hospital, the 
 eczema marginatum of Pick, Kobner, Ilebra and Hardy, the seborrhea 
 corporis of Duhring, the eczema seborrhoeicum of Unna. There has 
 always been a tendency to consider these eruptions as of parasitic 
 origin. 
 
 The name seborrheal eczema has proved decidedly the most 
 popular. Inna, as far back as 1887, not questioning the eczematous 
 character of the dermatosis thus named by him, pointed out that 
 the eruption preferably attacks the seats of election of seborrhea 
 and that, moreover, it -> scales or crusts have a fatty consistence. 
 The name coined by him Mas based on these observations. Being 
 struck, furthermore, by the fact that all intermediary degrees are 
 encountered between these eczemas with fatty scales and pityriasis 
 on one hand and certain forms of psoriasis on the other, he was led 
 
ECZEMATIDES 
 
 91 
 
 to extend immoderately the limits of seborrheal eczema. His 
 teachings, originally received with high favor, did not fail to arouse 
 severe criticism. On the one hand, the eczematous nature of the 
 process was contested, hence the name of seborrhoids, proposed by 
 Brocq and Audry; on the other hand, it was demonstrated that this 
 process is not invariably seborrheal. 
 
 The group has now been arbitrarily broken up: various con- 
 stituents are classified as steatoid pityriasis, by Sabouraud, as 
 medio-thoracic dermatosis and psoriatiform keratosis, by Brocq, etc. 
 
 Fig. 14. — Figured eczematide of the interscapular region of the back. 
 
 In my own opinion, the prevailing confusion on this subject would 
 practically disappear by keeping in mind: (1) that there exists a 
 cutaneous dystrophy which I have named kerosis (XI), ordinarily 
 manifesting itself through pityriasis and seborrhea; (2) that this 
 kerotic soil is a seat of predilection for the development of various 
 inflammatory complications which very frequently assume the 
 
Ml' 
 
 ERYTHEMATO-SQUAMOUS DERMATOSES 
 
 clinical form of eczematides or sometimes that of moist eczema, 
 or still other forms, such as rosacea, acne, etc. 
 
 The eczematides are then-fore interpreted by me as dry and cir- 
 cumscribed eczemas, which on account of these characteristics 
 deserve to be distinguished from the ordinary eczemas, and which 
 in the vast majority of eases, though not invariably, develop on a 
 kerotic soil. 
 
 Fig. l ■">. Figured eczematide of the forehead (corona seborrhoica, qoI to be 
 
 confused with the "corona veneris"). 
 
 Symptoms. The eczematides are practically always preceded 
 and accompanied in their vicinity by manifestations of kerosis. 
 In the mildest degree, it is very difficult to discern if the complica- 
 tion exists or not; a judgment must he based on the presence of 
 circumscribed and scaly redness. 
 
 Well-developed eczematides possess typical characteristics, differ- 
 ing slightly according to their seat and variety. 
 
 1 . Figured Eczematides. This first group corresponds to "eczema 
 llanellaire," the petaloid and circumscribed type of Unna, the 
 steatoid pityriasis of Sabouraud, the medio-thoracic figured derma- 
 tosis of Brocq, the seborrhea corporis of Duhring. 
 
ECZEMATIDES 93 
 
 The eruption at the onset almost invariably occupies the pre- 
 sternal and interscapular regions; from here it extends to a greater 
 or less distance from the median line according to its severity and 
 duration. It is seen also on the scalp, whence it extends to the fore- 
 head, temples and postauricular region. 
 
 The lesions begin as pinkish punctiform spots covered with a 
 greasy scale. Next, they spread as nummular, petaloid or poly- 
 cyclic, coalescent, more or less numerous spots, having the following 
 characteristics: sharply marked outlines; pinkish or bright red, 
 often slightly elevated papular borders, covered with yellowish 
 scales and crusts which are of a fatty consistence when squeezed 
 between two fingers ; a flattened surface, on a level with the normal 
 skin, of a yellowish pink color, often covered with scales less thick 
 than on the margins; no apparent vesicles and no infiltration of the 
 base. Scraping the margin with the finger-nail or with a curette 
 causes the appearance, according to Brocq, of a minute purpura, 
 droplets of serous fluid and, finally, small punctiform hemorrhages. 
 
 While extending, some of the spots heal in the center or in a portion 
 of their periphery. In the zone of invasion, the follicular orifices are 
 often attacked first, which explains the name of acneiform eczema, 
 proposed by Bazin. Pruritus is moderate and intermittent or it 
 may be altogether absent. 
 
 The duration of the eruption is indefinite and patients are not 
 uncommonly met with who have suffered from it for twelve or 
 fifteen years. Appropriate treatment causes it to disappear in ten 
 to fifteen days. 
 
 2. Pityriasis orm Eczematides.- — The characteristic features of 
 these cases are less definite. The lesions consist of pinkish or 
 yellowish pink spots, with a surface covered with fine scales, dry or 
 slightly oily in the kerotic areas and rather distinctly circumscribed. 
 Their form is round, oval, or irregular; their dimensions and number 
 are very variable. 
 
 The lesions may occur anywhere, but especially on the scalp and 
 the neighboring skin, on the neck, the upper part of the trunk, the 
 axillae, the groins, the articular folds in general and more rarely on 
 the extremities. 
 
 Sometimes the eruption is profuse, more or less symmetrically 
 arranged, appearing in rather rapid attacks and composed of 
 lenticular, nummular, or more extensive plaques, usually marginate, 
 dotting the thorax and the abdomen. Up to a certain point, this 
 variety can be recognized in the description of circinate and marginate 
 pityriasis (Vidal), of herpes tonsurans maculosus (Hebra, Kaposi) 
 and of psoriatif orm parakeratosis in scattered patches (Brocq) . It 
 approximates the pityriasis rosea of Gibert. In the absence of treat- 
 ment, its duration is from a few weeks to several months. 
 
94 
 
 ERYTHEMA TO-SQ UA MO US DERMA TOSES 
 
 In other cases the lesions are not numerous, localized without 
 symmetry, limited for instance to a large articular fold, developing 
 
 Fig. 16. — Pityriasiform eczematides. 
 
 I [G. 17. 
 
 -Pityriasiform eczematide, with a lichenoid tendency, located on the 
 posterior border of the righl axilla in a young woman. 
 
 insidiously, gradually acquiring ;i rather considerable extent and 
 persisting indefinitely. The spots, from being at first simply con- 
 gestive and furfuraceous, may assume a lichenoid appearance, or 
 
ECZEMATIDES 
 
 95 
 
 pass into a psoriatiform type; they are apt to present a marginate 
 or circinate outline with a yellowish center. 
 
 In both cases, but especially in the localized variety, the pityriasi- 
 form eczematides may become temporarily vesicular or oozing 
 (eczematized seborrhoids of some authors) ; then they subside again, 
 unless they continue to develop into moist eczema. 
 
 Fig. 18. — Psoriatiform eczematides on the hip of a middle-aged woman; note 
 that on the trunk the lesions become confluent, as erythrodermia. 
 
 3. Psoriatiform Eczematides. — Their topography and the configu- 
 ration of the lesions are entirely analogous to the preceding form. 
 But the spots have a brighter red, or tawny hue with a slightly 
 infiltrated base, profusely covered with more or less adherent white 
 scales. When subjected to the systematic scraping 1 of Brocq, they 
 yield, however, less numerous and less stratified lamellae than the 
 
 1 The "grattage methodique" of Brccq consist in the careful scratching of the 
 surface of a lesion with the aid of a dull curette; the resulting oozing, bleeding, 
 purpura, etc., vary in a characteristic manner in different diseases. — Ed. 
 
90 ERYTHEMATOSQUAMOUS DERMATOSES 
 
 spots of psoriasis; the red surface, on exposure, is slightly irregular 
 and scattered over with purpuric spots, fine hemorrhages, and cup- 
 shaped depressions from which a little serous fluid exudes, these 
 depressions representing a pathognomonic feature. The lesions of a 
 psoriatiform eczematide may be fairly abundant, covering a con- 
 siderable portion of the integument (Fig. 18) and even becoming 
 regionally confluent in large erythrodermic patches, covered with 
 scaly crusts; often they are few in number, or there may be only 
 a single large patch on any part of the body; for instance, on the 
 neck, in a fold, or on the calf of the leg. 
 
 In this variety, moist eczematization with formation of vesicles, 
 oozing and even impetiginization or lichenization is not uncommon. 
 
 Itching may be very severe, a symptom which may lead to pos- 
 sible confusion with a partial prurigo. 
 
 There exists finally, (4) a peripilar type and (5) an erythrodermic 
 type of eczematides, which will be discussed in the chapter dealing 
 with the folliculoses (p. 395) and the erythrodermas (p. 120). 
 
 Diagnosis. — This is by no means easy in all cases. A little atten- 
 tion will suffice, however, in the case of figured eczematides, to avoid 
 confusion with a desiccated impetigo, with circinate syphilides, with 
 lupus erythematodes, etc. 
 
 Pityriasiform eczematides are distinguished from pityriasis rosea 
 of Gibert by the often larger dimensions of their lesions and by the 
 less systematic evolution of the eruption. There are borderline 
 cases, however, in which the question arises if a legitimate distinc- 
 tion can be drawn between the two types of disease. Other cases 
 suggest a cutaneous trichophytosis; the latter is characterized by 
 the perfect roundness of the spots, by their marginal vesiculation 
 and by the demonstration of the mycelium on microscopical exami- 
 nation of the scales. Syphilitic roseola is never scaly. In psoriasis, 
 even when mild, the scales are more profuse. 
 
 The variety with large patches is suggestive of intertrigo-erythema, 
 of eczema marginatum of Hebra and of erythrasma; it simulates 
 especially a circumscribed eczematized prurigo. When it presents 
 oozing, crusts, lichenization and many erosions, the diagnosis can 
 sometimes not be made until after treatment for several days. 
 
 Between the psoriatiform eczematides and genuine psoriasis, there 
 is no definite objective difference; the distinctive features are based 
 on the topography of the eruption, its course, its tendency to oozing 
 and on the effect of treatment; the diagnosis in a given case must 
 sometimes lie held in abeyance. 
 
 Pathological Anatomy. Although somewhat dissimilar at first 
 sight, the histological lesions of the eczematides are always of the 
 same kind, no matter what variety be studied, and all transition 
 forms are met with between these varieties. 
 
ECZEMATIDES 
 
 97 
 
 The essential lesions are: Spongiosis, in small foci; parakeratosis, 
 often discontinuous; scaly crusts; acanthosis; in the cutis a little 
 edema with perivascular infiltration. 
 
 Fig. 19. — Section of figured eczematide. X 27. The central portion of the 
 nummular spot is not shown in the sketch, only the two borders of the lesion being 
 represented. A, spongiosis; B, crust; C, parakeratosis; D, acanthosis; E, crust; F, 
 spongiosis. 
 
 In the figured form (Fig. 19), provided the lesion is in active 
 progression and not at a stationary stage, as frequently happens, 
 very minute foci of spongiosis, too small to constitute vesicles 
 visible to the unaided eye may be seen near the borders or more 
 rarely in the center. Originating in the rete, these foci are pushed 
 up in the course of the epidermal development as far as the horny 
 layer, when their desiccated plasma mixed with the layers of para- 
 
 Fig. 20. — Psoriatiform eczematide. Entire section of a very small lesion. X 30. 
 A, spongiosis; B, focus of desiccated spongiosis; C, scale crust; D, parakeratosis; E, 
 spongiosis; F, parakeratosis; G, spongiosis; H, papillary edema and congestion; I, 
 cellular infiltration. 
 
 keratotic cells gives rise to small lenticular crusts; the latter, in spite 
 of their oily consistence, contain less fat demonstrable by osmic acid 
 than the normal horny layer. In the center of the spots only a low 
 degree of acanthosis is found. Edema of the papillary body and 
 perivascular cellular infiltration are marked only near the borders, 
 which are abrupt or gently sloping. 
 
 The psoriatiform variety simulates psoriasis, histologically (Fig. 
 
98 ERYTHEMATO-SQUAMOUS DERMATOSES 
 
 20) as well as clinically. The differences are as follows: The super- 
 ficial layer is a thick scaly crust, in which are found, between the 
 layers of nucleated horny cells (scales), collections of desiccated 
 serum and leukocytes (crusts). The parakeratosis may be con- 
 tinuous over the entire lesions, or interrupted. The acanthosis and 
 lengthening of the papillae are nearly as marked, although less regular 
 than in psoriasis; the crests of the papillae do not reach so near to 
 the horny layer. In the papillary body very small foci of spongiosis 
 may be discovered here and there, corresponding to a more abundant 
 cellular infiltration in the adjacent papillae. These are the foci of 
 spongiosis which are destined to become crusts on reaching the horny 
 layer. The papillary edema and the perivascular cuffs are a little 
 more pronounced than in psoriasis (Fig. 23). 
 
 Summarizing, these lesions constitute an epidermo-dermatitis of 
 eczema type, but more discrete, less acute and less edematous. It 
 will be readily understood that the exaggeration of the process will 
 result in eczema vulgare. 
 
 Etiology.— Eczematides are extremely common. They are 
 observed at all ages, especially in the course of adolescence, youth 
 and maturity. Many persons suffer from the affection without 
 attaching importance to it. A considerable number of eczemas are 
 derived from, or begin under this form. 
 
 Clinical analysis had formerly led to the conclusion that the 
 dry figured eczemas are parasitic. According to Unna, seborrheal 
 eczema is due to morococci, micrococci found in the crusts in mul- 
 berry-shaped clusters. Others believe that the seborrhea provokes 
 eczema (Dubreuilh), or creates the necessary soil, hence the name of 
 seborrhoids. Audry and Brocq, who proposed the last denomination, 
 have demonstrated, however, that these eruptions can exist without 
 seborrhea. 
 
 The relations between the eczematides and kerosis have been 
 discussed above. In my opinion, kerosis creates a peculiar predis- 
 position for the attenuated eczematization which constitutes the 
 eczematides. In all probability, the complication is the result of a 
 local mierobic infection. The responsible species is not yet known, 
 whether it be the staphylococcus cutis communis or the poly- 
 morphous coccus with gray cultures (Sabouraud), or other staphy- 
 lococci; nor do we know if a certain degree of virulence is essential, 
 or a certain symbiosis, for example, with the spores of Malassez 
 (bottle-bacillus of Unna, microsporon anomaon of Vidal), or if 
 there exists a specific microorganism which has so far escaped 
 detection. Recent investigations of Du Hois (Geneva) on this 
 subject indicate that the scale of the young lesions of pityriasiforrn 
 eczematides- which can always be lifted as a whole with a scarifier 
 or a fine bistoury — bears on its deep aspect collections of round 
 
PITYRIASIS ROSEA OF GIBERT 99 
 
 spores, of different dimensions and without mycelium; he was unable 
 to grow cultures of this parasite or to inoculate the germ, which is 
 probably identical with Vidal's microsporon anomceon or dispar. 
 The same parasite is found in the scales of the pityriasis rosea of 
 Gibert. The question therefore still remains open. 
 
 Treatment. — Whereas the treatment of eczema and psoriasis is 
 difficult and often disappointing, the eczematides usually yield 
 favorable results, easily obtained. 
 
 In the sluggish, especially the non-eczematized forms, treatment 
 may consist of rather energetic local applications, grading the 
 strength of the remedy according to the intensity of the lesions. 
 
 It is often advisable first to clean the spots, namely, to remove the 
 scales or crusts. This is accomplished by means of soapy, alkaline, 
 or sulphurous baths, by moist dressings, or more simply by washing 
 twice daily with white soap, potash soao, or a sulphur or tar soap. 
 
 Directly afterward, or simultaneously, local agents are employed, 
 salves, plasters and especially compound pastes, whose active sub- 
 stances are selected from the reducing agents: arsenic-zinc-sulphur 
 paste or if this be thought too irritant, ichthyol paste, or glycerol 
 preparations with ichthyol may be employed. More powerful 
 reducing agents may also be used such as chrysarobin or pyrogallol 
 in very small doses. 
 
 The psoriatiform eczematides sometimes offer considerable resis- 
 tance to treatment. They are managed like psoriasis but with 
 doses of progressively increasing strength, and cautiously for fear 
 of exciting acute eczematization. Compounds of tar and sulphur, 
 for example, and radiotherapy constitute very valuable adjuvants 
 in difficult cases. 
 
 On the scalp, sulphur lotions are employed, with ointments 
 containing the same active substance. 
 
 Internal treatment, by diet and medicinal agents, plays practically 
 no part in the eczematides; or rather, it is identical with that of 
 kerosis. 
 
 PITYRIASIS ROSEA OF GIBERT. 
 
 Pityriasis rosea of Gibert — pityriasis maculata et circinata of 
 Duhring, roseola squamosa of Fournier, herpes tonsurans maculosus 
 of Kaposi — is an erythemato-squamous dermatosis, characterized 
 (1) by its lesions; (2) by its topographical distribution; and (3) 
 especially by its course. 
 
 Symptoms. — The eruption, which itches severely, slightly or not 
 at all, consists of two kinds of lesions. Some are pinkish, scaly, 
 irregularly rounded lenticular or nummular spots, with not abso- 
 lutely distinct margins; they may become confluent in plaques or in 
 patches, 
 
100 ERYTHEMATOSQUAMOUS DERMATOSES 
 
 The others are more characteristic; known as "medallions," they 
 are larger, almost invariably elliptical, pinkish and squamous on 
 their slightly elevated borders and have a yellowish center where 
 the epidermis is finely puckered as in atrophic strife. These two 
 kinds of lesions are present in variable proportions: the larger 
 lesions, "medallions" may be rare and have to be looked for or they 
 may be absent at a given moment. 
 
 Pityriasis rosea may occupy the entire trunk, the neck and the 
 limbs, but it almost invariably spares the face above the chin, the 
 hands and the feet. The immunity of the hairy scalp is worthy of 
 special mention . The susceptible regions are not affected all at once, 
 but symmetrically and nearly always in a certain order. 
 
 The course of this affection is one of its most peculiar features. 
 The disease is almost definitely cyclic, so that pityriasis rosea has 
 been described as a pseudo-exanthema. 
 
 Frequently — as was first pointed out by Brocq — the eruption is 
 introduced by a primary patch, or initial plaque, occupying any 
 portion of the trunk, neck, or limbs. It is erythemato-squamous, 
 fairly well outlined, more or less pruritic, often circinate, and is 
 usually misinterpreted as a patch of trichophytosis or an eczematide. 
 Two or three such patches may be present. Judging from my 
 persona] experience, the initial plaque remains undetected, or is 
 entirely absent, in about one-half of the cases. 
 
 From four to twenty days later, or sometimes from the start, the 
 pinkish spots and "medallions" appear in profuse crops, first on the 
 upper part of the thorax, on the neck and arms, then on the flanks, 
 the abdomen and the thighs, finally on the forearms and sometimes 
 on the legs. 
 
 The eruption is accordingly successive, progressive and descend- 
 ing. It is afebrile and unaccompanied by disturbances of the 
 general health. 
 
 At the end of a month to six weeks, two and a half months at 
 most, the spots which begin to fade in the regions first affected, 
 disappear completely without leaving a trace behind. 
 
 1 have observed a recurrence of pityriasis rosea at the end of four 
 years in the same patient, but this is very exceptional. 
 
 Pathological Anatomy. — The pathological anatomy reveals more 
 lesions than might have been anticipated. Aside from a congestion 
 of the papillary body, with edema and rather marked perivascular 
 cellular infiltration, Sabouraud has pointed out the regular presence 
 in the border of the spots, of microscopical foci of spongiosis and 
 numerous superficial histological vesicles. The latter are never 
 clinically demonstrable and contain only mononuclear leukocytes, 
 but apparently no microorganisms. 
 
PITYRIASIS ROSEA OF GIBERT 101 
 
 The scales are parakeratotic and interspersed with these desiccated 
 vesicles. No mycelium or special parasites are demonstrable and a 
 remarkable confusion has led Hebra and Kaposi to describe pity- 
 riasis rosea as a trichophytosis, under the name of herpes tonsurans 
 maculosus. 
 
 Diagnosis. — Pityriasis rosea of Gibert differs from the eczematides, 
 by its "medallions," by its symmetrical distribution, by its invariable 
 absence from the scalp, and especially by its regular and cyclic 
 development, which terminates in spontaneous cure in a definite 
 time — though sometimes, the immediate diagnosis must be left 
 open; from psoriasis, by its much less vivid redness, its fine non- 
 stratified scales and its course; from toxic and infectious erythemas, 
 by its "medallions" and its desquamation. 
 
 An unpardonable error, one that may lead to great domestic dis- 
 tress, is unfortunately sometimes committed, when a case of pity- 
 riasis rosea is mistaken for a syphilitic roseola; the latter is never 
 scaly, does not form "medallions" and is associated with a hard 
 chancre, mucous patches or at least with glandular enlargement. 
 
 Etiology and Character. — As to its nature and cause, pityriasis 
 rosea remains a problem. It is known preferably to attack youthful 
 individuals, especially young girls and women; to be more common 
 in the spring and fall and in persons suffering from digestive dis- 
 turbances. It shows no predilection for cases of kerosis. 
 
 Its initial plaque, its course, its spontaneous cure after a certain 
 lapse of time and its non-recurrence, speak in favor of a systemic 
 infection . No instances of contagion are known . Long ago, Lassar 
 advanced the view that pityriasis rosea might result from an exog- 
 enous cutaneous infection, the unknown germ being transmitted 
 by new or bleached underwear; Jadassohn believes this view to be 
 justified in a number of the cases. 
 
 Treatment.— It is better to omit all treatment of an eruption which 
 always heals spontaneously than to aggravate it by the use of soap, 
 sulphur baths, or irritative topical applications which congest the 
 skin, aggravate the pruritus and sometimes give rise to a real eczema- 
 tization. 
 
 Dusting with a bland powder may suffice. It has seemed to me 
 that coal-tar in small doses, particularly ichthyol, 2 per cent, in a 
 cream or a glycerol, visibly hastened the fading of the lesions. 
 Jadassohn recommends chrysarobin pastes of very weak concen- 
 tration (1 in 3000 to 1 in 1000); others prefer sulphur pastes, or 
 especially aqueous pastes. [Calamine lotion with the addition of 
 10 per cent, of precipitated sulphur, or, in very pruritic cases, of 2 per 
 cent, of phenol is a satisfactory application.] 
 
102 ERYTHEMATOSQUA MOl r S DERMATOSES 
 
 PSORIASIS. 
 
 Psoriasis is one of the most important dermatoses, through its 
 frequency, the multiplicity and extent of it^ lesions and its rebellious 
 
 character. 
 
 Symptoms. 'Die lesion of psoriasis is typical. In its most 
 common form, it is a bright red, sharply circumscribed spot, covered 
 with dry, nacreous, laminated, friable and abundant scales; the 
 base of the spot is not infiltrated and there is no itching (Fig. 21). 
 
 Scratching these lesions causes two characteristic signs: (1) on 
 scratching with the fingernail, the scale breaks down into a fine 
 white micaceous dust; (2) after the scale has been removed by the 
 fingernail a red shining surface is exposed showing fine punctiform 
 hemorrhages. 
 
 Fig. 21. — Nummular psoriasis "ii the wrist, large plaque on the forearm, with 
 psoriatic arthropathies of the hand ami fingers. 
 
 The last-named sign, known as Auspitz' sign, the importance of 
 which was shown by Hebra and Devergie, has been more fully 
 analyzed and worked out by L. Duncan Bulkley and by the recent 
 investigations of Brocq. It will he again referred to later. 
 
 It i> frequently demonstrable, on careful inspection, that the 
 psoriasis >pots arc surrounded 1>,\ a [talc halo, from 1 to 8 mm. wide, 
 the skin of which i> healthy, hut slightly blanched. 
 
 The lesions of psoriasis are usually rounded or oval in shape. 
 They may be of au\ size from a pin-point or pin-head, a drop of 
 wax, or a coin, to immense patches, covering an entire region of the 
 body. As a rule the lesions of the same eruption have rather uni- 
 form dimensions, hence the terms psoriasis punctata, [guttata], 
 nummularis, discoides, etc., which have merely a descriptive value. 
 
 Sometimes, the lesions have the shape of psoriatic rings, from 
 \ to 1 cm. wide, enclosing an area of healthy skin, or fragments of 
 
PSORIASIS 
 
 103 
 
 rings and arabesque designs, constituting psoriasis gyrata or figurata, 
 formerly described under the objectionable name of lepra vulgaris; 
 or they may be marginate plaques, the result of healing from the 
 centre. 
 
 Fig. 22. — Psoriasis, general topography of the eruption. 
 
 The eruption is accompanied by no general disturbances; psoriasis 
 is pruritic only in inebriates and in some nervous subjects. 
 
 The number of lesions is infinitely variable, from a few isolated 
 spots to several hundreds. The eruption at its origin appears either 
 
104 ERYTHEMATOSQUAMOUS DERMATOSES 
 
 as minute red papules which fade even on scratching, or as concen- 
 trically growing guttate lesions which rather rapidly reach their 
 permanent dimensions, or primarily as patches of nummular size. 
 
 In its distribution, typical psoriasis shows a marked tendency to 
 symmetry and a predilection for bony prominences (Fig. 22); the 
 elbows and the knees, the scalp and the sacrum (sacral plaque) are 
 especially the seats of the largest, most typical and most obstinate 
 patches. However, all regions of the integument including the face, 
 the palms and the soles, the red border of the lips, and the semi- 
 mucosse of the genital organs may be affected, but the mucous 
 membranes are always free. The "buccal psoriasis" of the older 
 authors is simply leukoplakia (p. 219). 
 
 On the scalp, which rarely escapes and is sometimes the sole seat 
 of the affection, the psoriasis spots or patches are characterized by 
 their sharp limitation, the abundance of white or grayish scales, in 
 a continuous or micaceous layer, covering a red non-oozing surface. 
 It is noteworthy that the hairs are preserved, appear dry, pass 
 through the scales and do not come out on traction, contrary to 
 what happens in the eczematides of this region and in the tineas. 
 
 Varieties. — There occur anomalies of eruptive form or of distribu- 
 tion and regional varieties. Sometimes the spots of psoriasis are 
 faintly outlined, superficial, light pink and covered with not very 
 profuse slightly yellowish scales resembling pityriasis. This attenu- 
 ated psoriasis, which is often seen on the face and occasionally on the 
 genital organs, is sometimes difficult to distinguish from the eczema- 
 tides. 
 
 Psoriasis spots, even when small, may exceptionally have a slightly 
 infiltrated base, solid to the touch and almost papular; representing 
 infiltrated psoriasis. This modification occurs especially at the 
 border of the annular and carcinate lesions of figured psoriasis. 
 Somewhat extensive spots or patches of long-standing psoriasis are 
 always more or less thickened and sometimes even lichenoid: 
 psoriasis inveterata. In certain regions, for example, on the legs, 
 the surface exceptionally becomes roughened or papillomatous. 
 Frequently, old and figured patches are covered with a nacreous, 
 oystershell-like keratotic layer of stratified and adherent scales. 
 
 In other cases, especially in the articular folds, psoriasis may have 
 the appearance of vivid red plaques, denuded of scales, or covered 
 with crusts, or freely oozing like an eczema rubrum; the borders are 
 sometimes irregular. The nature of this oozing psoriasis, or eczema- 
 psoriasis of the old authors, is doubtful. Are these cases a special 
 form of psoriasis, or are they an eczematized psoriasis, even though 
 the integument of such patients is usually very rebellious to artificial 
 eczematization; or are they a psoriatiform eczematide? It seems 
 probable that there are cases to which each of these interpretations 
 
PSORIASIS 105 
 
 may be applied. It is not uncommon to find typical spots of psoriasis 
 on the elbows and knees of these patient. 
 
 In some cases of genuine psoriasis, the almost exclusive localiza- 
 tion on the flexor surfaces of the articular folds, the groins, axillae, 
 as well as on the genitals and often on the palms and soles, con- 
 stitute a type known as psoriasis inversa. The eruption assumes the 
 form of large bright red patches, the skin being smooth and tense. 
 It is found in the victims of diabetes, overexertion or intoxication. 
 It is often very obstinate and apt to become irritated by any form 
 of medication. 
 
 This variety more often than the typical forms, becomes associated 
 with secondary erythrodermas of the benign or malignant "herpe- 
 tide" type (p. 122); sometimes, the onset of this complication is 
 attributable to badly tolerated medicinal applications. 
 
 The distribution which is indicated in the names of palmar and 
 plantar psoriasis (p. 215); ungual psoriasis (p. 435) and psoriasis 
 universalis (p. 120), will be described in other chapters. 
 
 A very important clinical form because undoubtedly the most 
 serious, is the arthropathia psoriasis, studied especially by Bourdillon. 
 
 The frequency of articular manifestations in psoriasis is estimated 
 at 5 per cent, of the cases; and in my opinion this estimate is too low. 
 [They are by no means so frequent in America]. Often, these are 
 merely arthralgias, myalgias and melalgias, resembling indefinite 
 subacute rheumatism; this is psoriasis dolorosa. In other cases, 
 either dating from the first eruption or after the lapse of a few 
 years, progressive nodular, bony or fibrous arthropathies super- 
 vene, affecting the joints of several fingers (Fig. 21), one or more 
 large joints and sometimes entire limbs and the vertebral column, 
 leading to deformities with ankylosis and contractions which con- 
 stitute most painful and deplorable infirmities. 
 
 The differential feature of these arthropathies from those of mul- 
 tiple arthritis deformans — with which they have many analogies — 
 aside from their coincidence with the eruption, is their predilection 
 for the male sex, youths and adults rather than old men, their more 
 abrupt course, the frequent presence of hydrarthroses and the pre- 
 dominance of swelling among the deformities; finally, the absence 
 of all regularity of the invasion. These features likewise charac- 
 terize the tuberculous pseudo-rheumatism of Poncet. 
 
 Arthropathic psoriasis, being too common to admit of an explana- 
 tion by simple coincidence, constitutes an argument for certain 
 authors in favor of a nervous origin, for others (Audry, Petges, etc.) 
 in favor of the tuberculous origin of psoriasis, or rather of certain 
 forms of psoriasis. 
 
 Course. — Psoriasis runs its course in more or less abrupt attacks 
 in different cases and is of very variable duration. The first attack 
 
100 ERYTHEMATOSQUAMOUS DERMA TOSES 
 
 is often more acute and composed of many small lesions, but this is 
 not an absolute rule. Subsequent attacks supervene without any 
 regularity and often in the absence of a demonstrable determining 
 cause. 
 
 In the interval between attacks, especially under the influence of 
 appropriate treatment, the patient is "bleached," in the sense that 
 the lesions fade, sometimes leaving a dark deep-pigmented macule 
 which persists a few months before it disappears. Such patients, 
 however, are by no means to be considered as cured. 
 
 Sometimes, two or three more obstinate spots resist all therapeutic 
 efforts and persist indefinitely. It is moreover in the nature of the 
 disease to recur during almost the entire lifetime of the patient. 
 The skin rarely remains perfectly free for more than two or three 
 years in these cases. There are innumerable cases of discrete psoriasis, 
 without severe attacks, but incessantly persistent or recurrent. 
 
 In aged persons, the disease becomes attenuated or extinct, some- 
 times leaving behind it a sort of persistent pityriasic desquamation. 
 
 Diagnosis. — This is based on the characteristic features of the 
 lesions, those of the eruption and of the disease. The properties 
 belonging to the psoriasis spot cannot be over-emphasized. Their 
 recapitulation here is unnecessary, but on account of their great 
 importance, I must refer again to the data furnished by systematic 
 grattage according to the method of Brocq. 
 
 In a typical lesion of psoriasis, under the successive layers of 
 micaceous scales, a red and smooth surface is reached, from which 
 a fine pellicle can be detached, coming off in shreds several centi- 
 meters square; underneath it fine droplets of blood exude, sometimes 
 after a little lapse of time; but purpuric spots are rare and no drops 
 of serous fluid are obtained, as in the eczematides. 
 
 As regards the eruption, without referring to its customary dis- 
 tribution, it is to be noted that in psoriasis, all the lesions are psorias- 
 iform, a condition which is not found in the diseases which simulate 
 it (psoriatiform syphilides, etc.). 
 
 It would be superfluous to dwell on the differential features dis- 
 tinguishing psoriasis from lichen planus, lichen corneus, premycotic 
 patches, Lupus erythematodes, pityriasis rubra pilaris and the other 
 erythemato-squamous dermatoses treated in this chapter; these 
 differences will be manifest from the description of these various 
 affections. 
 
 Pathological Anatomy. — The principal lesion of psoriasis is para- 
 keratosis, or change of keratinization characterized by the disappear- 
 ance of the stratum granulosum and by the persistence of flattened 
 nuclei in the cells of the horny layer. The horny layer is also less 
 oily than in the normal state, its stratifications accumulate, but are 
 easily split into lamellae (Fig. 23). 
 
PSORIASIS 107 
 
 The rete is hypertrophied and considerably thickened (acanthosis) 
 between the papilla? which are greatly elongated and cylindrical 
 (papillomatosis) ; but it is thinned above the crests of these papillae 
 which are separated from the parakeratotic horny layer only by a 
 few layers of flattened cells. The papilla? and the papillary body are 
 slightly edematous and their bloodvessels are dilated and surrounded 
 by a small number of round cells; the lesions of the derma are insig- 
 nificant. 
 
 .. < '. ' :.' :V 
 
 
 Fig. 23. — Histology of psoriasis. General section of a small but long standing 
 lesion of the elbow. X 50. A, parakeratosis; B, acanthosis; C, papillomatosis; D, 
 
 These changes explain the clinical symptoms; the redness is refer- 
 able to the congestion, to the elevation of the papillary crests and 
 to the absence of an opaque keratohyaline layer. The desquamation 
 and the peculiar powdery scaling evident upon scratching depend 
 upon the cleavage and the friability of the parakeratotic horny layer. 
 The smooth sub-squamous membrane is made up of the layers of 
 flattened Malpighian cells; it is due to the slight thickness of this 
 layer and its softness that the adjacent vascular papilla? are easily 
 injured with the nails, whence the punctiform hemorrhages. Acan- 
 thosis and infiltration are more marked in inveterate psoriasis with 
 more or less lichenoid patches. 
 
 The parakeratosis, owing to which the epidermis is now composed 
 of only two layers, like that, for instance, of orificial mucosa, is not 
 specific for psoriasis. It is the substratum of many forms of des- 
 quamation especially of the psoriasiform type; it is observed, for 
 example, in the dermatitides, in recent cicatrices, after the spongiosis 
 of eczema and the eczematides, in the psoriatiform syphilides, etc. 
 
 In psoriasis itself, it is apparently only secondary. The investi- 
 gations of Munro (1898) and of Sabouraud, confirmed by those of 
 Paul Haslund (1913) have shown that aside from the lesions of the 
 
108 ERYTHEMATOSQUAMOUS DERMATOSES 
 
 stationary stage which I have described, small miliary abscesses 
 containing leukocytes but without demonstrable microbes, may be 
 observed in incipient or progressing psoriasis; these minute abscesses 
 form in the subcorneal layer of the rete and are successively pushed 
 up into the horny layer where they appear as a layer of desiccated 
 cells. When the eruption is actively progressing, they are very 
 numerous and succeed one another rapidly and incessantly at the 
 same point or at neighboring points. This lesion is considered by 
 Sabouraud as pathognomonic of psoriasis and, reasoning on these 
 premises, he groups under the heading of psoriasis more than half 
 of the seborrhoids or eczematides. The minute abscesses of psoriasis 
 actually bear a close resemblance to the small foci of spongiosis 
 which I have emphasized in the eczematides; when the two forms of 
 microscopic lesions are confused, the histological differentiation 
 becomes very difficult and in certain cases must rest on a single 
 characteristic, namely the extreme paucity of microbes taking stains 
 in sections of psoriasis, whereas there is an abundance of organisms 
 in the eczematides. 
 
 Etiology and Character. — Psoriasis occurs in all countries and 
 climates, somewhat more frequently in men. It may appear at 
 any age, from two to eighty years, but is most common around the 
 period of puberty and during adolescence. [It constitutes from 3 to 
 5 per cent, of all cases seen in dermatological practice.] Psoriasis is 
 not contagious. It seems to be hereditary, or familial, in one- 
 fifteenth to one-twentieth of the cases. 
 
 In favor of its external parasitic origin have been urged the sharp 
 limitation and the centrifugal development of its lesions; its occur- 
 rence, in psoriatics, in localities traumatized by vaccination, tattoo- 
 ing, friction of suspenders or other tight articles of clothing, scratches 
 made with a pin; a feature as a matter of fact which suggests auto- 
 inoculation. Destot (Lyons) is said to have successfully inoculated 
 himself with psoriasis, but his experiment does not appear convincing. 
 Arguments may also be based on the therapeutic action of parasi- 
 ticidal topical applications. But the direct examination of the 
 minute abscesses invariably shows them to be free from microbes 
 and in the scales the common microbes are extremely rare. In the 
 studies on the etiology of psoriasis directed by J. F. Schamberg 
 (1913) no special microorganism in the skin or the blood of psoriatics 
 was found. The parasitic theory, although reasonable, is by no 
 means proved. 
 
 The relations of psoriasis with arthritism and with the dyscrasias 
 rest on a few facts, but are neither accurate nor demonstrable. To 
 describe a tendency to psoriasis as herpetism, is merely a play on 
 words. 
 
 Too rich a diet, especially in albuminoid substances, seems to be 
 
PSORIASIS 109 
 
 capable of favoring the first appearance, or at any rate the eruptive 
 outbreaks, of psoriasis. 
 
 The theory of the nervous origin of psoriasis is supported by the 
 usual symmetry of the eruption, its occasional appearance in con- 
 nection with a serious accident or emotional shock, the coexistence 
 of neuralgias and arthropathies. It has been claimed by several 
 observers that psoriasis manifested itself relatively often in the 
 participants of the late war. If this be true (which is doubtful), 
 a number of other causes besides emotion might be involved (too 
 much meat, etc.) 
 
 Of recent years, several authors have advanced the view of a 
 possible connection between psoriasis, or certain forms of psoriasis, 
 and attenuated tuberculosis. Although it is certain that the arthrop- 
 athies of psoriasis present marked analogies with the tuberculous 
 rheumatism of Poncet, the great majority of psoriatics do not 
 convey the impression of being the subjects of tuberculosis. Psoriasis 
 and tuberculosis are so common, moreover, that there is nothing 
 remarkable about their frequent coincidence. Brocq groups 
 psoriasis under his "cutaneous reactions," and admits that it may 
 develop under the influence of a number of occasional causes, or 
 without this influence through the effect of disturbances of the 
 general conditions not yet determined by chemical analysis. These 
 indefinite phrases aptly express our ignorance concerning the true 
 character of this dermatosis. 
 
 Treatment. — This must be in the first place external and local. 
 It comprises two stages: 
 
 1. Cleansing. — It is indispensable to clean and free the patches 
 from their scaly covering before the medicinal agents are made to 
 act upon them. This is accomplished by more or less prolonged 
 soapy, alkaline, or tar baths, or steam baths, or by moist or rubber- 
 ized dressings. In most cases vaseline or glycerol inunctions, soft 
 soap, lard, etc., are used. Salicylated vaseline (5 per cent.) with 
 applications of green soap twice daily, seems to be the most rapid 
 procedure; at the end of a few days, we may pass on to other 
 remedies. 
 
 2. Reducing Agents. — All reducing agents (see Therapeutic 
 Notes) are capable of healing the patches of psoriasis. Treatment is 
 begun with the weakest, with the tars, especially oil of cade the 
 virtues of which have long been tried, in the form of salves, glycerol- 
 ated, or in the pure state. More or less deodorized and decolor- 
 ized extracts have been prepared, known as lenicade, oxycade, etc., 
 which are liked by patients [but are less effective]. 
 
 The mercurials (calomel, turpeth mineral, etc.) or sulphur, etc., 
 are reserved for the scalp and the face. The addition of salicylic 
 acid (1 per cent.) increases their action. It must be kept in mind 
 
110 ER Y THE MA TO-SQ UA MO US DERMA TOSES 
 
 that a mixture of sulphur and a mercurial salt would dye the hair 
 and the same remark applies to naphthol. 
 
 Strong reducing agents, or salves containing such agents, which 
 are efficient but irritating should not he employed except in rather 
 scanty eruptions and when the patient can be watched. 
 
 Chrysarobin is the best; it is employed as an ointment with 
 ichthyol, or preferably as a varnish with traumaticine. It acts only 
 when an erythema is produced, which however, must remain 
 moderate. Alkaline baths and washes must be avoided during its 
 use. It stains the hair and linen a violet color and sometimes gives 
 rise to severe conjunctivitis. But it will sometimes bleach a case 
 of psoriasis in a fortnight. 
 
 Pyrogallic acid, in salves, varnishes, or in ethereal solutions, will 
 destroy the linen and blacken the epidermis and the hair; it is very 
 efficacious but difficult to handle on account of the danger of poison- 
 ing when it is employed on large surfaces. 
 
 Of the innumerable chemical products extolled abroad as anti- 
 psoriatics, none seems to me worthy of being retained. 
 
 Radiotherapy — the indications of which in psoriasis I pointed 
 out in 1898— may rapidly obliterate recent or even inveterate 
 patches which have first been cleansed. It is only applicable, 
 however, in circumscribed eruptions, and does not prevent recur- 
 rences. It is employed only in exceptional cases. 
 
 3. General Treatment. — This is much less important. Arsenic 
 has been regarded as a specific and administered in all its forms; 
 moderate doses are often beneficial; energetic arsenical medication 
 subjects the patient to the risk of intense pigmentation and may 
 produce a genuine leuko-melanodermia. The arsenobenzols are free 
 from this drawback and are sometimes very successful but must be 
 handled very cautiously. 
 
 Potassium iodide, in enormous doses from 15 to 25 grams daily has 
 been advocated; I have obtained no results from it. Injections of 
 calomel, or of yellow oxide, by themselves alone have sufficed to 
 cure some cases of typical psoriasis and to improve markedly 
 arthropathic psoriasis; unfortunately they are not reliable. Experi- 
 ments are now under way with injections of sulphur in solution. 
 
 It goes without saying that proper hygienic measures should be 
 recommended with abstinence from alcohol and stimulants. Schain- 
 berg and his associates (Philadelphia Research Laboratories) have 
 emphasized a habitual nitrogen retention in these cases and the 
 favorable influence of a vegetable diet poor in nitrogen, as pre- 
 viously recommended by Bulkley, Besnier and others. 
 
 Warm mineral springs and sulphur waters are useful in some 
 cases. 
 
PARAPSORIASIS 
 
 111 
 
 PARAPSORIASIS. 
 
 Under this provisional name, Brocq in 1902 grouped several rare 
 and unclassifiable dermatological types, characterized by non- 
 pruriginous erythemato-squamous spots, extremely persistent and 
 rebellious to all treatment. 
 
 It is exclusively the objective appearance of these dermatoses 
 which led to their mutual approximation to psoriasis. Their origin 
 and character are unknown, hardly even surmised, and probably 
 variable. 
 
 Three types are distinguished: 
 
 Parapsoriasis Guttata. — This eruption is disseminated over the 
 trunk and limbs in faintly pink or brownish-red lenticular spots, 
 very slightly infiltrated, covered with dry adherent scales, com- 
 parable to a sealing wafer. Scratching of these spots gives rise to 
 fine purpuric puncta. The eruption resembles an abortive guttate 
 psoriasis, or a resolving papulo-squamous syphilide. It is main- 
 tained by the appearance of new lesions, originating separately or 
 in crops. 
 
 Fig. 24. — Lichenoid parapsoriasis dating back four years, in a man aged thirty-two 
 
 years. 
 
 Parapsoriasis Lichenoides. — This type differs from the preced- 
 ing by the more papular, more infiltrated and less psoriatiform 
 
112 
 
 ER J ' THEM A TO-SQ UA MO US DERMA TOSES 
 
 character of the lesions. These appear in the form of bright pink, 
 hemispherical or flattened, glistening and non-scaly papules; later 
 on, the lesion becomes purplish and bears a scale which seems to be 
 imbedded in a depression of the papule; finally there remains only 
 a yellowish macule with slight atrophy of the epidermis. The erup- 
 tion is scattered over the trunk and the limbs or is arranged in 
 clusters and network; it is not at all pruritic. The reproduction of 
 the lesions during years in the same regions gives the skin a pecu- 
 liarly mottled appearance (Fig. 24). The differential diagnosis 
 must be made from lichen scrofulosum and other tuberculides, 
 lichen planus, syphilides and psoriasis. The cases published by 
 Unna [and Pollitzer], Jadassohn, Xeisser, Pinkus, Crocker, etc., 
 under the names of parakeratosis variegata, lichen psoriasis, pity- 
 riasis lichenoides chronica, etc., belong to the first two forms. 
 
 25. — Parapsoriasis in patches of thirty years' standing on the flank of a man, 
 aged forty-seven years. 
 
 Parapsoriasis in Plaques. —It consists of circumscribed spots or 
 patches of a yellowish pink or wine color, with few or no scales, non- 
 infiltrated and oon-pruritic; their configuration is round, oval, zoni- 
 i'oini, annular or reticulate (Fig. 25); their arrangement varies 
 slightly from year to year; on their surface the texture of the skin 
 is modified and the normal mosaic more marked. The eruption 
 occupies the trunk and the limbs. It resembles the eczematides, 
 
PSORIATIFORM SYPHILIDES 113 
 
 premycotic plaques, or tertiary syphilitic erythemas. This type 
 was described in 1897 by Brocq, and later by J. C. White, under the 
 name of pityriasic erythroderma in disseminated patches. Crocker 
 gave this form the name of xantho-erythroderma perstans. 
 
 The histology of parapsoriasis, very carefully studied by Civatte, 
 presents briefly the following lesions : Edema and congestion of the 
 papillary body, with perivascular cuffs consisting especially of lym- 
 phocytes, sometimes collections suggestive of lichen scrofulosum; a 
 rather atrophic Malpighian layer with small areas of parakeratosis. 
 
 Parapsoriasis appears at all ages, especially during youth and 
 maturity, its duration is indefinite; the lesions disappear, while 
 others insidiously supervene. Its nature is unknown; in some of the 
 cases the patients were old syphilitics; on the other hand, the theory 
 maintained by Civatte, according to which the disease is a tuber- 
 culide, is based on strong clinical and pathologico-anatomical argu- 
 ments. 
 
 All local medication is ineffectual ; injections of arsenical prepara- 
 tions and of mercury have seemed to me useful in some cases. 
 
 PSORIATIFORM SYPHILIDES. 
 
 Strictly speaking erythemato-squamous syphilides do not exist. 
 However, as it is always in connection with syphilis that the question 
 of the diagnosis of pityriasis rosea, psoriasis, etc., arises, and as 
 errors are frequent, I believe the insertion of the following para- 
 graph will be useful. 
 
 In the first place, let me point out that syphilitic roseola is 
 never squamous or scaly (A. Fournier), whereas, pityriasis rosea and 
 psoriasis are always scaly. 
 
 As to the papular syphilides of secondary lues, these are habitually 
 slightly scaly, but may become so to a degree which entitles them to 
 the epithet of psoriatiform. 
 
 Their dimensions are miliary, lenticular, or nummular; their 
 form is round, orbicular, sometimes annular in certain regions; 
 their color is pink or red, but often dull, purplish, not so vivid as 
 the lesions of psoriasis. Although desquamation may be profuse, 
 it is nevertheless not so abundant as in psoriasis; scratching reveals 
 no subcorneal pellicle and very readily produces traumatic purpura. 
 
 But the sign par excellence of the syphilides, on which the diagnosis 
 must always rest, is their firm resistant infiltration, their hardened, 
 neoplastic consistence; they have substance, according to an 
 expression used by A. Fournier. The lesions of recent psoriasis, 
 on the contrary, are pliable and not indurated. All this signifies 
 that in spite of their apparent anology, syphilis really produces 
 squamous papules, whereas psoriasis gives rise to squamous macules. 
 
 The eruption of psoriatiform syphilides is irregularly scattered 
 
114 ERYTHEMATO-SQUAMOUS DERMATOSES 
 
 everywhere, often confluent on the face, the back, the nape of the 
 neck; no patches are found on the elbows, knees and scalp. The 
 eruption is more or less polymorphous, not all the lesions are 
 psoriatif orm ; finally, there are coincident glandular swellings or 
 adenopathies, mucous patches, etc.; briefly, signs of syphilis, and the 
 Wasserniann reaction is positive. 
 
 The tubercular syphilides of tertiary lues may be abundantly 
 squamous and psoriatif orm. However, they are firm to the touch, 
 usually circinate, always segregated, regional, not very numerous. 
 Moreover, healing is followed by cicatrices. 
 
 ERYTHEMATO-SQUAMOUS EPIDERMO-MYCOSES. 
 
 Several parasitic cutaneous diseases, due to vegetable parasites, 
 may assume the form of red and squamous spots. 
 
 This is rarely the case in pityriasis versicolor; its spots are yellow- 
 ish or brownish; exceptionally they may be of a pink color. It is 
 noteworthy that one of the peculiarities of microsporon furfur is that 
 it produces practically no congestive or inflammatory reaction. 
 
 Erythrasma. — This affection on the contrary often leads to con- 
 fusion, especially with the pityriasiform eczematides in large patches. 
 It is distinguished by the dryness of its scales, by its localization, 
 by its persistence, by the almost complete absence of pruritus, and 
 especially by the presence of the microsporon minutissimum in 
 large numbers in the epidermis (p. 532). 
 
 Trichophytosis of the Smooth Skin.— This is characterized by the 
 generally perfect orbicularity of the red and squamous spots, by 
 their relatively rapid and regular peripheral development, by the 
 rather frequent presence, especially on their borders, of vesicles which 
 have earned for this affection the name of herpes circinatus (p. 522). 
 
 Epidermophytosis. — The rapidly extensive, red and squamous 
 spots, with polycyclic contours, bordered by small vesicles or a 
 scaly margin, which develop in the groin and in the large cuta- 
 neous folds, constituting the eczema marginatum of Ilebra, are due 
 to the epidermophyton inguinale; the microscope readily reveals 
 the mycelium of the parasite in the scales (p. 524). 
 
 Microsporosis. Various microsporons may vegetate on the 
 hairless skin; the spots caused by them are of irregular form, 
 indistinctly outlined, more pityriasic than erythematous and very 
 readily curable (p. 527). 
 
 Favus Cutaneus. — This may appear without "cups" in the form 
 of red and squamous, rarely vesicular, distinctly outlined and fairly 
 regular rounded spots (favus herpeticus) ; the achorion is abundantly 
 represented in the scales. 
 
 Tropical Epidermomycoses— These are discussed elsewhere in 
 this book (p. 528). 
 
CHAPTER VI. 
 ERYTHRODERMAS. 
 
 The name erythroderma is applied to a very extensive or general- 
 ized, persistent and squamous inflammatory reddening of the skin. 
 
 The symptom of extensive and persistent redness is very easily 
 demonstrable; but as it occurs under very different pathological 
 conditions, its significance and value vary to a high degree. 
 
 The redness of erythroderma is inflammatory, so that very exten- 
 sive vascular nevi, for example, do not belong under this heading. 
 The vascular congestion is sometimes accompanied by a certain 
 degree of swelling or retraction of the tissues ; the skin feels warm 
 to the touch, but the patients frequently complain of a constant cold 
 sensation. 
 
 The redness is very extensive; however, the erythrodermas are 
 practically limited in degree to the chronic erythemas and the 
 erythemato-squamous dermatoses. 
 
 It is persistent. The meaning of this word is somewhat elastic; 
 usually, to be declared as erythrodermic, the duration of a red 
 eruption must exceed seven days. 
 
 Finally, and especially, the erythrodermas are squamous from the 
 start or after a few days, very abundantly or scantily, under variable 
 forms, powdery, furfuraceous, lamellar or exfoliating, etc. The 
 epithet exfoliating or exfoliative applies to a considerable number of 
 the most characteristic types; other cases have been designated 
 under the name of pityriasis rubra. 
 
 The term "pityriasis" according to Besnier, is a simple dermo- 
 graphic expression specifying a particular form of epidermic des- 
 quamation in lamella? as fine as bran, or furfuraceous. It is a 
 traditional designation, not indicative of any relationship between 
 them, for cutaneous affections differing as widely as pityriasis 
 simplex, pityriasis versicolor, pityriasis rosea of Gibert, pityriasis 
 rubra pilaris. The common denomination "pityriasis rubra" 
 therefore does not apply to all erythrodermas and is reserved in 
 this book for the variety described by Hebra. 
 
 The symptom of erythroderma is met with under four different 
 conditions: (1) As a constituent of peculiar eruptions developing 
 on the healthy skin; these are the Primary Erythrodermas. (2) 
 Through the effect of generalization of one of the dermatoses with 
 
116 ERYTHRODERMAS 
 
 red and squamous spots, described in Chapter V; for this group 
 I reserve the name of Erythrodermic Dermatoses. (3) As a compli- 
 cation of a preexisting eruption; these arc the Secondary Erythro- 
 dermas. (4) Finally, there occur Congenital Erythroderma* and 
 cases developing in newborn infants. 
 
 I. PRIMARY ERYTHRODERMAS. 
 
 Acute forms have been described, lasting a few weeks; subacute 
 forms, lasting several months; and chronic forms, lasting a year or 
 longer. 
 
 This subdivision, although convenient for the grouping of obser- 
 vations, implies neither difference nor identity of character among 
 these clinical forms. 
 
 . 1 . Primary Acute Erythroderma. — This is a generalized erythema 
 with a foliaceous desquamation, of toxic or infectious origin, also 
 known under the name of Recurrent desquamative scarlatiniform 
 erythema ( Fereol and E. Besnier) and Acute benign exfoliating 
 dermatitis- (Brocq). 
 
 After two or three days of prodromata, in the form of prostration, 
 headache, chills, and fever of 38° or 39° [100° to 102°] the eruption 
 makes its appearance as a red pruritic surface in the large folds of 
 the trunk and the limbs; it becomes generalized in a few days, the 
 head sometimes escaping. 
 
 Before the redness disappears, desquamation begins and gradually 
 extends; it is locally furfuraceous but more apt to occur in large 
 collodium-like shreds or on the hands and feet, in the form of an 
 incomplete glove or sandal (Fig. 20). The skin underneath appears 
 smooth, sometimes still scaly, or oozing in the folds. The mucous 
 membranes may be affected; redness of the conjunctiva 3 , an ery- 
 thematous angina and desquamation of the tongue are noted. 
 The genera] condition becomes practically normal long before the 
 end of the cutaneous disease, which lasts about three weeks. The 
 nails remain marked by a transverse furrow; loss of hair is incon- 
 siderable. Relapses are frequent, at intervals of months or years, 
 but usually dimmish in severity. 
 
 The causes of this eruption are imperfectly understood. A neces- 
 sary predisposition and various causative factors are admitted. 
 First in order come the intoxications, notably mercury, the influence 
 of which should be looked for in all its forms: internal, external, 
 medicinal and accidental; picric acid, quinine, chloral, belladonna, 
 opium, may also be responsible. When toxiderma can be excluded, 
 infections are to be thought of, such as gonorrhea, malaria, strepto- 
 coccus infection, etc 
 
 The differential diagnosis must be made from the scarlatinoid 
 
PRIMARY ERYTHRODERMAS 
 
 117 
 
 erythemas, which are less extensive, more transitory and less 
 desquamative ; and especially from scarlet fever which is not recur- 
 rent, is accompanied by angina and more pronounced general 
 phenomena and has a more belated desquamation. [The most 
 important differential feature is found in the circumstance that the 
 exfoliation usually begins while the erythema is still pronounced; 
 but a diagnosis is often impossible and] in doubtful cases the same 
 prophylactic measures are called for as in the presence of scarlatina. 
 
 Fig. 26. — Acute primary erythroderma in the stage of desquamation following 
 ingestion of a mixture containing opium (Berge's case, Soc. Med. des Hop., February 
 22, 1907). 
 
 B. Primary Subacute Erythroderma. — This probably represents 
 merely a more prolonged and more serious form of the preceding 
 type; it is also known as generalized exfoliative or exfoliating derma- 
 titis of Wilson- Brocq. 
 
 The onset is the same, with or without prodromata; generaliza- 
 tion is complete, somewhat more gradually established; the folia- 
 ceous desquamation is so active that handfuls of epidermal shreds 
 may be gathered up in the morning from the patient's bed. The 
 mucous membranes and the appendages are always involved; the 
 nails and nearly all hairs of the body may fall out toward the end 
 of the third to fourth week. 
 
 The tension of the skin, the constant sensation of cold, the loss of 1 
 weight notwithstanding the good appetite, the diarrhea, the great 
 
118 
 
 ERYTHRODERMAS 
 
 diminution in nitrogen excretion and the hectic fever indicate the 
 gravity of the disease. Death occurs from cachexia or as the result 
 of complications, in one-sixth of the cases. The duration is from 
 three months to a year. 
 
 This rather uncommon subacute form is observed in adults, 
 especially in inebriates and in connection with some form of intoxi- 
 cation or auto-intoxication. Relapses hardly ever occur. 
 
 ( '. Primary Chronic Erythrodermias. At the present writing, three 
 types can be differentiated. 
 
 ititis of three years' standing, in a man aged 
 
 1 . The Chronic Form of the Exfoliative Dermatitis of Wilson-Brocq. — 
 Under this heading are grouped the cases analogous to primary 
 subacute erythroderma but lasting several years (Fig. 27). 
 
 2. Pityriasis Rubra of Hebra-Jadassohn. The erythema begins in 
 various regions, especially in the large folds, as red surface lesions 
 with furfuraceous scales, without infiltration or oozing. The 
 complete generalization takes place in a few months, at most two 
 years; chills are common and itching is variable. 
 
PRIMARY ERYTHRODERMAS 119 
 
 The skin gradually becomes thickened, then atrophied and 
 retracted to the point of interfering with movements. The appen- 
 dages fall out. Death supervenes at the end of a few years, in 
 a state of general marasmus and according to Jadassohn almost 
 invariably through tuberculosis. Since his investigations (1892) 
 there is a tendency to group pityriasis rubra under the heading of 
 the Tuberculides. 
 
 Cases of partial eruption have been reported, as well as subacute 
 benign cases, the interpretation of which is doubtful. 
 
 3. Premycotic and Leukemic Erythrodermas. — In male adults, the 
 onset of an erythroderma has been observed beginning with highly 
 pruritic red spots, becoming universal, scarlatinoid, more purplish 
 in the folds and dependent portions, sometimes with depressed 
 white spots scattered here and there. Desquamation is usually very 
 slight or it may be dry and lamellar. Febrile attacks may occur. 
 The nails usually remain intact, but the hairs fall out to a great 
 extent. 
 
 Three constant features attract attention : a frenzied irrepressible 
 pruritus, causing the nails to become worn off, edematous thickening 
 of the skin, which forms ridges toward the great folds and generalized 
 glandular swelling. 
 
 After a very long time, up to ten years or more, small cutaneous 
 nodosities may make their appearance, having the structure of 
 mycosis fungoides (p. 659) . 
 
 This premycotic erythroderma, pointed out by Besnier and 
 Hallopeau, may present prolonged remissions; it may also lead to 
 death from cachexia before the apperance of tumors. 
 
 The lymphoderma pemiciosa of Kaposi was probably an erythro- 
 derma of this kind, which became complicated by leukemia (p. 655). 
 
 The leukemic erythroderma studied by Audry, Nicolau, and others, 
 is a pathological type closely related to the preceding. Desquama- 
 tion is perhaps more profuse and pruritus less severe ; but especially, 
 in addition to the adenopathy, there is hypertrophy of the spleen 
 and a relative or absolute leukemia. Sometimes, the appearance 
 of small nodules in the skin, or papillomatous patches, has been 
 noted. Death is inevitable and may supervene in less than two years. 
 
 All cases of primary chronic erythroderma necessitate, from the 
 diagnostic and prognostic point of view, thorough clinical study with 
 careful examination of the viscera and glands, complete and repeated 
 examinations of the blood and sections of the skin and the glands, 
 for histological and bacteriological examination as well as animal 
 inoculation. Only in this way can we hope to determine the rela- 
 tions of pityriasis rubra and mycosis fungoides with the leukemias, 
 pseudoleukemias, tuberculosis, etc. 
 
120 ERYTHRODERMAS 
 
 n. ERYTHRODERMIC DERMATOSES. 
 
 Sonic of the great dermatoses may become erythrodermic through 
 generalization in the course of their evolution. In these cases, the 
 characteristics of the eruption persist, only modified by the extension 
 it lias undergone. 
 
 Generalized Eczema. -Generalized eczema proceeds in successive 
 relays, invading new territories and becomes permanently estab- 
 lished if the conditions of eczematosis exist in the patient; but it 
 rarely becomes universal. Even in these cases it retains its tendency 
 to recrudescences, paroxysms, oozing, to a reddened appearance and 
 severe itching. The mucous membranes remain intact and the 
 appendages are only gradually affected. The general condition is 
 far from being as seriously affected as in the cases of true erythro- 
 derma, whether primary or secondary. 
 
 The principal difficulty is the recognition of the nature of this 
 eczema, whether it is primary, or secondary to a prurigo, for instance, 
 ;u id on the other hand to discover the nutritional disturbances, 
 internal suppuration or visceral lesion of which it is often a mani- 
 festation, such as nephritis, cancer, etc. The treatment is not very 
 effective and must be very cautiously handled. 
 
 In generalized eczematide— pityriasis rubra seborrhceica of Unna, 
 or malignant exfoliating form of seborrheal eczema — the eruption 
 extends little by little but is rarely universal. The eruptive areas 
 or widely invaded regions are sometimes red and dry, covered with 
 pityriasis- fatty scales, sometimes oozing and covered with yellowish 
 scaly, not very adherent crusts, the contours are rounded or 
 polycyclic (see Fig. 18, abdominal region); in the folds and under 
 i he thick crusts, serous or purulent oozing is present in all cases. 
 
 It is often difficult, until a few days or weeks of treatment have 
 elapsed, to distinguish between a generalized eczematide, a primary 
 or secondary eczema and an eczematized psoriasis. The rounded 
 crusts may even suggest pemphigus. The general condition usually 
 remains favorable. The prognosis is less gloomy than that of the 
 other generalized dermatoses and especially that of exfoliating 
 berpetide (p. 122). It depends upon the degree of toleration of the 
 skin for the topical reducing agents which must here be employed 
 with moderation. 
 
 Psoriasis universalis may finally become absolute and total; the 
 redness is uniform from head to foot; the desquamation loses its 
 stratified and micaceous character, except at the seats of pre- 
 dilection; neither oozing, nor crusts, nor pruritus is present. The 
 hairs of the seal]) and body become scanty; the nails are striated 
 and ridged. Arthropathies may develop. 
 
 The course, without paroxysms, is of an absolutely chronic 
 
SECONDARY ERYTHRODERMAS 121 
 
 character. Treatment often remains completely ineffective ; although 
 I have obtained nearly complete but always temporary cures by 
 means of mercurial injections, using calomel or the yellow oxide. 
 The arsenobenzols might be given a trial. 
 
 Pityriasis rubra pilaris may exceptionally, at the onset or in 
 consequence of its progressive extension, present an erythrodermic 
 appearance. But healthy skin areas can always be demonstrated, 
 in distinctly outlined, sometimes angular islands as well as peripilar 
 cones on the borders of the surface lesions or at the points of election. 
 The desquamation is plaster-like and adherent. 
 
 Acute lichen planus, sometimes spreads over large surfaces and 
 may assume an erythrodermic appearance; this abnormal exten- 
 sion is usually initial and rapidly retrogressive. It soon becomes 
 possible to discover the characteristic papules, if necessary with the 
 assistance of a lens on the red surfaces themselves or at their borders. 
 
 Pemphigus foliaceus occasionally presents to a high degree the 
 clinical appearance of an abundantly exfoliating erythroderma. 
 The disease has generally passed at the onset through a stage of 
 bullous eruption and sometimes bullous lesions can be found 
 around the erythrodermic areas. The exfoliation of pemphigus 
 foliaceus is noteworthy for the moist or even oozing condition of the 
 tissues underneath the scales. 
 
 Equine scabies is a very rare disease which may appear under the 
 guise of erythroderma, as illustrated by the case of Besnier's and a 
 personal observation of my own. The redness is universal, involving 
 even the face and the scalp; the crusted or powdery scales predomin- 
 ate on the hands and feet; itching is not excessive. No burrows 
 can be detected; but even the smallest scale is seen under the 
 microscope to teem with the parasite (sarcoptes) in all its stages. 
 
 m. SECONDARY ERYTHRODERMAS. 
 
 . Generalization, as has been seen, leads to the so-called " erythro- 
 dermic" appearance in the great dermatoses which have just been 
 briefly reviewed. On the other hand, their course may be tempor- 
 arily arrested by, or it may terminate in a very extensive or even 
 universal exfoliating dermatitis; this marks and transforms the 
 characteristics of the first eruption and seems to take its place, 
 reproducing the aspect and behavior of a primary erythroderma. 
 
 In the first case, there has been an extension with more or less 
 complete preservation of the characteristics belonging to the first 
 eruption; the second case, where there is unification of the patho- 
 logical picture, was interpreted by the older authors as a transfor- 
 mation, whereas modern writers are inclined to see in it the effect of 
 a complication. 
 
122 ERYTHRODERMAS 
 
 It is readily understood that an investigation of the patient's 
 antecedents and preliminary condition is usually required in order 
 to establish the fact that the erythroderma is really secondary and 
 the nature of the dermatosis on the soil of which it has developed. 
 
 The secondary erythrodermas manifest themselves under two 
 forms, ordinarily designated by the traditional names of benign 
 herpetide and malignant herpetide. 
 
 Benign Form (episodic erythrodermas of Besnier). — The 
 erythrodermie complication may be partial, regional or very exten- 
 sive; rarely is it total; it is always transitory, lasting a few days to a 
 few weeks. There are valid reasons for ascribing it to the inoppor- 
 tune or badly tolerated intervention of an external medicinal agent, 
 such as a mercurial preparation, chrysarobin, picric acid, etc., or of 
 some internal medication. Relapses are extremely liable to occur. 
 
 Malignant Form (exfoliative herpetide of Bazin, chronic malig- 
 nant exfoliative dermatitis of Vidal and Leloir). — By Bazin, 
 who described it, exfoliative herpetide was interpreted as the 
 common outcome of certain eczemas, psoriasis, pityriasis; super- 
 vening by imperceptible transition and representing a sort of cachexia 
 of the skin, comparable to asystoly in heart disease. 
 
 The symptoms are those of the subacute form of primary erythro- 
 derma, but with less fever; there is, however, well-marked general 
 exhaustion and marasmus. The elimination of urea in the urine, 
 always greatly diminished, may be reduced to 10 or even 4 grams 
 per day; on the other hand, up to 10 grams of urea have been found 
 in the daily scales. 
 
 The prognosis is fatal although more or less prolonged remissions 
 have been observed. 
 
 There is a tendency to attribute this " malignant herpetide" to a 
 toxic, infectious or autotoxic complication of the same character 
 as that which gives rise to the primary erythrodermas. 
 
 IV. CONGENITAL ERYTHRODERMAS AND ERYTHRODERMAS 
 OF THE NEWBORN. 
 
 In little children, various types of congenital or acquired, tempo- 
 rary or persistent exfoliative erythrodermas have been observed. 
 The following cases must be distinguished : 
 
 1 . Lamellar Desquamation in the Newborn. — This represents an 
 exaggeration of the phenomenon of physiological desquamation 
 seen in many newborn infants and consists of desiccation and 
 splitting of the epidermis in the first days of life, followed by the 
 shedding of this epidermis, furfuraceous or in shreds, from the third 
 to fifth day up to the thirtieth or sixtieth, according to Parrot. 
 
 In rare cases, such as that observed by Grass and Torok (1S95), 
 
ERYTHRODERMAS OF THE NEWBORN 
 
 123 
 
 the child is bom with a sort of supra-epithelial collodium-like layer 
 (epitrichium) ; this splits after the first hour and in a few days 
 becomes detached in the form of large shreds ; the skin then becomes 
 normal again. 
 
 2. Exfoliative Dermatitis of Nurslings. — Described by Ritter von 
 Rittersheim (1878) begins during the first to fifth week of life, around 
 the mouth or, more rarely, in other parts of the body; it becomes 
 rapidly generalized over the entire integument and finally extends 
 to the extremities. The skin is of a purplish-red color and is des- 
 quamated in large dry shreds. Bulla? have sometimes been observed. 
 Certain authors believe that this affection is related to epidemic 
 pemphigus. As a rule, the disease is febrile and in one-half of the 
 cases it leads to death, often within a week. 
 
 Jf 
 
 ... j 111 
 
 wL 
 
 
 .. 
 
 ^^^^^ .JrtM 
 
 '■■' • . * ■ ".' 
 
 \ JssHaaHBM 
 
 Fig. 28. — Erythroderma in a newborn infant (generalized eczematide.) 
 
 3. Generalized Dermatoses. — Various generalized dermatoses, in- 
 cluding medicinal, mercurial and other eruptions, are encountered 
 in children. 
 
 I have published a case of seborrheal eczema or eczematide in an 
 
1 24 ERYTHRODERMAS 
 
 otherwise healthy child of five weeks ( Fig. 28); onset at the ear. 
 almost total generalization in nine days; scarlatinoid redness with 
 dry scales or greasy crusts, in different localities; recovery in 
 three weeks. 
 
 Desquamative Erythroderma of Nurslings, described l>y ('. Leiner 
 in 1907, is a morphologically analogous morbid type. He was 
 enabled to observe 43 cases, usually beginning on the scalp, 
 with 1") deaths. Beck's record of 16 personal cases, in which the 
 disease usually began on the buttocks, confirms the observation 
 that this grave eruption, which seems to be of toxic character, is 
 peculiar to breast-fed children suffering from enteritis. A change of 
 alimentation is urgently required. 
 
 4. Diffuse Congenital Hyperkeratosis. — Also known as congenital 
 or fetal ichthyosis, or ichthyosis sebacea (Kaposi), is a cutaneous 
 malformation of which several degrees are known: 
 
 The severe type (diffuse congenital malignant keratoma) [harlequin 
 fetus] \> incompatible with life. The infant, born at term or pre- 
 maturely, presents a dreadful appearance; its entire skin is red 
 and tense, as if too tight, fissured, covered with large yellowish 
 layers or crusts several millimeters thick, apparently resulting from 
 the desiccation of a sebaceous coating. The face is formless; move- 
 ments of the limbs are almost impossible; the child is unable to 
 suckle and promptly succumbs to cold. 
 
 The benign type (generalized ichthyosiform hyperkeratosis) is not 
 ■fatal; it is usually confused with ichthyosis. It will be discovered 
 in the chapter on the Keratoses (p. 203). 
 
 Pathological Anatomy of the Erythrodermas. — The lesions of all 
 erythrodermas are associated with vascular congestion, a variable 
 cellular infiltration in the papillary body, with more or less edema 
 and pigmentation and corneal exfoliation, the mechanism of which 
 usually remains obscure. 
 
 Reliable histological investigations are not numerous and have 
 yielded divergent results in forms bearing the same label. At the 
 present writing a differential histological diagnosis between the 
 various types is out of the question. The following are the few 
 available data on this subject: 
 
 In the primary subacute erythrodermas there is claimed to be 
 parakeratosis, intrapapillary infiltration with enlargement of the 
 papillae. Central, ganglionic and peripheral nervous lesions have 
 been described by Mario Oro. 
 
 In the pityriasis rubra of Hebra the papillary body, at first 
 infiltrated, later on undergoes atrophic changes; the glands and 
 follicles disappear; the stratum granulosum is diminished or absent. 
 In a very remarkable case Brunsgaard found in sections of the skin 
 typical tubercles with giant cells and Koch's bacilli. It had already 
 
ERYTHRODERMAS OF THE NEWBORN 
 
 125 
 
 been shown by Jadassohn that in autopsies on cases of pityriasis 
 rubra, tuberculosis was found in various organs in seven out of 
 eight cases. 
 
 Premycotic erythroderma represents the most distinctive ana- 
 tomical type. The illustration gives a fairly accurate idea of the 
 condition (Fig. 29). 
 
 Fig. 29. — Histology of premycotic erythroderma. The dominant lesion con- 
 sists of a very dense cellular infiltration (F) , occupying the papillary body and 
 having a sharp lower boundary; it is composed of lymphoid cells arranged in an 
 adenoid network. The afferent vessels of the chorion (G) are surrounded by cellular 
 cuffs. The papillse (E) are enlarged and elongated. The interpapillary buds (A) 
 are drawn out and often bifid. The horny layer (B) is thick and desquamating. 
 Parakeratosis is noted in places (C). In the rete may be seen minute cellular nests 
 (£)) filled with lymphocytes; those are inconstant, but possess great diagnostic value, 
 being specific of mycosis fungoides. X 65. 
 
 In the malignant exfoliative herpetides there exist parakeratosis, 
 according to Leloir, and a destructive change of the connective- 
 tissue fibers, especially around the vessels, with preservation of the 
 elastic fibers. These lesions, which were reported as characteristic, 
 could not be confirmed by Mario Oro. 
 
 The generalized dermatoses preserve the histological lesions 
 peculiar to them, although with some modifications. 
 
 Treatment of the Erythrodermas. — The most essential requirement 
 is to ascertain with great care the possible cause of the erythroderma. 
 When there is reason to suspect an intoxication, or some external 
 agent, this injurious factor must, of course, be removed. An 
 existing auto-intoxication should be controlled by dietetic measures, 
 free ingestion of water, enteroclysis, injections of glucose or other 
 sera, together with general hygiene. With special reference to 
 
126 ERYTHRODERMAS 
 
 mycosis fungoides and the leukemias and pseudoleukemias, radio- 
 therapy is known to furnish a valuable method, if not for a cure at 
 least for improvement and retardation of the course of the disease. 
 
 Local Treatment must aim especially at non nocere. It comprises, 
 depending on the case, prolonged or even permanent emollient 
 baths, such as were formerly given abroad; moist aseptic dressings, 
 or applications of oil and lime-water liniment, which are very 
 troublesome to handle but afford a marked relief for the pruritus; 
 finally, wrapping in cotton. It is often useful to cover the patient 
 [thickly and continuously] with a bland powder between two sheets 
 and to apply lotions only here and there or partial inunctions 
 with a paste or a cream. Caoutchouc must be very cautiously 
 employed; it will blanch certain erythrodermas, it is true, but 
 seems to be capable of inducing very dangerous repercussions. 
 
 All these topical agents are merely palliatives, aiming at the 
 relief of the patient and the prevention of complications. They 
 represent simply a marked form of expectant treatment. 
 
CHAPTER VII. 
 PAPULES AND PAPULAR DERMATOSES. 
 
 The eruptive lesions described as papules are small solid ele- 
 vations which subside spontaneously. The terms of this definition 
 may be stated with greater precision, as follows: 
 
 The papules are circumscribed elevations of small dimensions; 
 they have the size of a pin-head, a lentil or at most a large pea; they 
 are always protuberant, but to a very variable degree. 
 
 The papules are solid, which means that they do not contain an 
 effused fluid; it is sometimes necessary to prick them with a needle 
 in order to ascertain this fact. Finally, papules do not persist indefi- 
 nitely, a feature which distinguishes them from small tumors of 
 the same appearance; they disappear of their own accord, without 
 leaving a scar, which differentiates them from tubercles; this is 
 expressed in the statement that they undergo spontaneous resolution. 
 
 Many papules develop exclusively at the site of the hair- 
 follicles; these follicular papules will be discussed with the folliculoses 
 (XIX). 
 
 The papular prominence may become associated with various 
 processes, for instance hemorrhage {papular purpura); vesicle form- 
 ation in certain eczemas (papulo-vesicular eczema), and formation 
 of pustules (papulo-necrotic tuberculides), etc. 
 
 Very large papules are sometimes designated as papulo-tubercles. 
 
 It sometimes happens that an infiltration similar to that which 
 constitutes the papules, instead of being closely restricted to a very 
 small surface, is spread out on the contrary in coin-shaped (num- 
 mular) discs or in patches and becomes superimposed on an erythe- 
 matous, erythemato-squamous, etc., process. In such cases, although 
 these expressions are not, strictly speaking, correct, it is customary 
 to employ the terms of papular plaques or patches. 
 
 Anatomical Characteristics of the Papules. — The eruptive lesion 
 known as a papule may be produced through different pathological 
 processes. According as they affect chiefly the epidermis or the 
 derma or the two tissues alike, a distinction is made between 
 epidermic papules, dermic papules and mixed papules. 
 
 Epidermic Papules.— Epidermic papules are most typically 
 represented by the flat warts (Fig. 30) . In these, all the layers of the 
 epidermis are hypertrophied, the mucous body (acanthosis) as well 
 
12S 
 
 PAPULES AND PAPULAR DERMATOSES 
 
 as the granular layer (granulosis) and the horny layer (keratosis). 
 The papillae are elongated (papillomatosis) up to ten times their 
 normal height. There is very little edematous or cellular infiltra- 
 tion in the derma. 
 
 y u'v 
 
 ■'■-r~'-.^ '- 
 
 . KiRMAHSHI. 
 
 Fig. 30. — Section of an epidermic papule. Flat wart of the face. A, keratosis; 
 B, granulosis; C, acanthosis; D, papillomatosis. X 33. 
 
 Iii the papule of prurigo, the rete mucosum especially is hyper- 
 trophied, being three to four times thicker than normal; the con- 
 dition of the horny layer and of the papillte is extremely variable. 
 
 Dermic Papules. — Dermic papules are of two kinds depending 
 on whether the substance which causes the prominence is an 
 edematous fluid or an inflammatory cellular infiltrate. 
 
 f^f^N 
 
 i- -&.; 
 
 
 Fig. 31. — Section of a dermic papule. Lenticular papular syphilide. X 25. 
 
 
 The edematous papule is seen in urticaria and papular erythema; 
 the local congestion and exudation of plasma between the meshes of 
 the papillary body disappear in part, at the same time as the blood- 
 pressure, in the cadaver and in excised segments; hardening of the 
 
MIXED PAPULES 129 
 
 specimen in alcohol entirely obliterates the lesions. When the eryth- 
 ema-papule is not purely urticarial, but more or less infiltrated, it 
 is found to contain perivascular collections composed mainly of 
 leukocytes. 
 
 The most typical example of infiltrated papules is furnished by 
 lenticular papular sypkilides (Fig. 31). The epidermis here is 
 passively distended, thinned, sometimes with corneal exfoliation. 
 The papillary body and the upper layer of the corium are the seat of 
 a very abundant compact infiltration of cells, among which plasma 
 cells predominate with a few giant cells ; at the periphery of the main 
 focus the infiltration consists of perivascular cuffs of plasmocytes. 
 
 The papule of lichen scrofulosorum is also essentially dermic; 
 it is found to contain an infiltration of cells of various kinds, lym- 
 phoid, epithelioid and giant cells, often arranged as tubercles, either 
 in the papillary body or in the vicinity of pilo-sebaceous follicles. 
 
 Mixed Papules. — In the mixed papules there exist combined 
 epidermic and dermic lesions. The papule of lichen planus, which 
 belongs to this type, consists of acanthosis, with more or less 
 keratosis and a limited infiltration of the papillary body; the 
 granular layer is hypertrophied here and there. 
 
 The papule of strophulus has a thickened epidermis with localized 
 spongiosis and an edematous infiltrated dermic base. 
 
 Clinical Characteristics of the Papules. — A trained observer will 
 have no special difficulty in the clinical distinction of the different 
 varieties of papules. The epidermic hypertrophy manifests itself as a 
 superficial, dry and hard, often yellowish prominence, which is in no 
 way reducible on pressure. 
 
 Edematous papules are pinkish-white, tense but compressible; 
 they can be reduced by pressure with the finger-nail, but resume 
 their shape after a few minutes. 
 
 The dermic cellular infiltration produces a pink or red papule 
 which is more profoundly indurated, resistant and elastic. 
 
 The condition of the horny layer at the surface of the papule is of 
 great importance, depending on the existing dermatosis; it may be 
 thickened or stretched, desquamating in more or less friable and 
 abundant lamellse or transformed into scales, crusts, and so forth. 
 
 The differential diagnosis of papules in general is based upon 
 their objective appearance and their course. In the first place, 
 care must be taken not to confuse them with vesicles or pustules, 
 which contain a fluid; with the tubercles of syphilis, leprosy, 
 lupus or with tuberculides, which leave cicatrices; finally, with 
 tumors of small dimensions, which are indefinitely persistent 
 or progressive, such as: various nevi, sebaceous adenomas and 
 hidradenomas, small cysts, circumscribed keratomas, epitheliomas, 
 tumors of molluscum contagiosum, etc. 
 
130 PAPULES AND PAPULAR DERMATOSES 
 
 In some cases a careful examination, pressure under a glass slide 
 (vitropressure), expression of the contents, puncture with a needle 
 or sometimes even the removal and examination of a piece of 
 tissue for biopsy may be necessary. 
 
 The following syndromes will be described in this chapter: 
 Juvenile flat warts, which represent a special clinical variety of 
 common warts. Lichen planus, with typical papular eruption, as 
 well as its atypical varieties, which should be studied in this connec- 
 tion, in spite of the irregular features assumed by the eruption; the 
 papules of prurigo, as eruptive lesions, the disease as such being 
 discussed in a separate chapter (XXIV); typical papular syphil- 
 itic*; finally, the papular form of tuberculides known as lichen 
 scrofulosorum. 
 
 JUVENILE FLAT WARTS. 
 
 The warts designated under this name appear as an eruption 
 of small epidermic papules, not more than 3 mm. in diameter, flat- 
 tened and barely protuberant; they have rounded or irregularly 
 polygonal contours, are sharply circumscribed, have the color of the 
 normal skin or show a yellowish, grayish or brownish tint; their 
 surface is finely puckered or slightly scaly; they cause no itching. 
 
 The warts are met with especially on the face, more particularly 
 the cheeks, temples, forehead and chin, from a few up to several 
 hundred in number. They may also occupy the back of the hands, 
 associated or not with common warts, but are less frequent on the 
 forearms. I have counted over 1500 on a young girl whose face, 
 neck and even chest were dotted with them. 
 
 These warts undoubtedly result from auto-inoculation or through 
 transmission from other flat warts, probably also from common 
 warts existing on the patient himself or in persons of his environ- 
 ment. Children, young girls and young women are particularly 
 susceptible. In men, they may be spread by means of the razor. 
 
 After having multiplied and persisted for months or sometimes 
 years, these flat warts finally disappear spontaneously without leav- 
 ing ;i trace. 
 
 The treatment must therefore aim especially at avoiding produc- 
 tion of scars. Caustic agents must not be used. Tainting with an 
 exfoliating mixture is usually prescribed (Therapeutic Notes, Sec- 
 tion 5). Radiotherapy will cure flat warts with astonishing rapidity; 
 a single session, with moderate dosage, is often sufficient. High- 
 frequency sparks are likewise very successful. Jadassohn empha- 
 sizes the efficacy of arsenic treatment. Suggestion probably plays 
 a part in certain cures and the same remark is true for common 
 warts. 
 
LICHEN PLANUS 
 
 131 
 
 LICHEN PLANUS. 
 
 The term lichen was applied by Willan (and since his time) 
 to dermatoses of different character. At the present time, the 
 existence of a lichen " genus" comprising several species is no longer 
 admissible. With the simple use of the term lichen, we now refer 
 to the great and well defined dermatosis — also known as lichen 
 planus, lichen ruber planus or Wilson's lichen — to be described in 
 the following. 
 
 The expressions: lichen simplex, lichen obtusus, lichen corneus, 
 lichen scrofulosorum, will be defined further on. 
 
 Fig. 32. — Lichen planus of the wrist and the palm of the hand. 
 
 Symptoms. — The eruptive lesion of lichen planus is a typical 
 papule, of the average dimensions of a pin-head, of polygonal flat- 
 tened form, sometimes depressed or umbilicated; its surface is 
 smooth and shining; its consistence is dry and firm; its color varies 
 from a yellowish pink, which is the most common, to a dusky or 
 purplish red; sometimes the color does not differ from that of the 
 normal skin. 
 
 These sufficiently characteristic features are often combined with 
 another, which is pathognomonic : the presence of white or grayish 
 opaline streaks and dots marking on the surface of the papules a 
 network or nodular arborizations or stars on a pink background. 
 The "sign of the net," the importance of which was emphasized by 
 L, Wickham, is distinctly visible only on well-developed papules, 
 
i:;: 
 
 PAPULES AST) PAPULAR DERMATOSES 
 
 which may be isolated or grouped in patches; in order to demon- 
 strate the net, it is advisable to moisten the papules with water, 
 or paraffin oil, or better with anilin oil which renders the horny 
 layers transparent. 
 
 The incipient papules are punctiform, pink and glistening; they 
 enlarge in a few days or weeks. Full-grown papules may remain 
 isolated in discrete eruptions, but almost invariably they multiply 
 and become confluent in plaques of very variable extent and round, 
 oval, or irregular shape, usually thicker on the borders than in the 
 middle, of a dusky red or brownish color. 
 
 Their surface is covered with fine, very adherent, often scarcely 
 visible scales, but the finger-nail passing over the surface leaves a 
 scaly line. Horny granules are sometimes seen. The papules con- 
 stituting the patch are sometimes recognizable, especially on the 
 borders. Extensive plaques and patches, when there is complete 
 confluence, are cut in squares by lozenge-shaped or polygonal 
 designs Inning a smooth and glistening surface, producing a mosaic 
 appearance. On the surrounding -kin isolated papules and other 
 groupings may be seen. 
 
 Fig. 33 
 
 It is the rule for lichen planus, especially when the eruption has 
 existed for ;i few weeks, to be accompanied by dyschromia. The 
 papules and patches become more or less pigmented or become 
 surrounded by ;i pigmented areola; sometimes, the center is color- 
 less while the circumference is hyperpigmented, brownish or 
 blackish. Tin- symptom may be absent. The coexistence of 
 genuine vitiligo is not very rare. 
 
 The most common localization of the eruption is the anterior 
 surface of the wrists, the forearms and the legs; but it is also 
 observed on the flanks, the lumbar region, the genital organs, the 
 buccal mucosa, the neck, the palmar and plantar regions, rarely on 
 the face and very exceptionally on the hairy scalp. The eruption 
 may be almost universal, 
 
LICHEN PLANUS 133 
 
 Pruritus may be altogether absent, often it is slight and inter- 
 mittent; sometimes, very severe and even excessive to the point of 
 interfering with rest. It may therefore be said that patients suffer- 
 ing from lichen planus scratch themselves, "a little, a great deal, 
 violently, or not at all." 
 
 Scratching is undoubtedly responsible for the diffuse lichenization 
 which frequently accompanies the typical eruption, sometimes 
 concealing it. 
 
 Varieties. — There exist several varieties of lichen planus char- 
 acterized by a particular form of the eruptive lesions, or of their 
 arrangement, by certain localizations, or by an abnormal course 
 of the disease. 
 
 The papules of lichen planus may assume the form of very 
 regular rings, from 6 to 8 mm. in diameter, with a pigmented center; 
 this form is encountered especially on the genital regions, on the 
 internal surface of the arms, on the flanks and near the articular 
 folds. The existence of a few rings in a typical eruption is not 
 uncommon; they may predominate in a given region, constituting 
 lichen annulatus. 
 
 Sometimes, in the same regions, the papules are grouped in circles, 
 with centrifugal extension, in gyrate or arabesque patterns; this 
 condition is described as lichen marginatus sen serpiginosus. 
 
 There also occurs an arrangement of the papules in linear streaks, 
 apparently referable to streaks from scratching: lichen striatus; or 
 following the course of a nerve after the manner of herpes zoster 
 or a linear nevus: lichen zoniformis. 
 
 In certain cases of lichen planus taking an acute or subacute 
 course, the typical lesions may be associated with a few acuminate 
 papules. It might be conceded that this partial and occasional 
 irregularity is entitled to the special name of lichen acuminatus. 
 However, at the International Congress held in Paris in 1889, the 
 foreign authors present admitted that the majority of the cases, 
 which with Kaposi they called lichen ruber acuminatus, actually 
 belonged to pityriasis rubra pilaris, [described by Devergie and 
 long known in France.] 
 
 In the palmar and plantar regions (Fig. 32) the papules of lichen 
 are sometimes horny, resembling vesicles at first sight; this des- 
 quamation gives rise to a peculiar cribriform appearance. In other 
 cases, the eruption manifests itself in the form of large irregularly 
 outlined red and scaly spots, so that the diagnosis is far from easy. 
 
 Lichen planus of the buccal mucosa is especially noteworthy on 
 account of its frequency and its peculiar appearance. Familiarity 
 with its characteristics may assist in the diagnosis of a doubtful 
 case. Ignorance concerning them leads on the contrary to the 
 unfortunately frequent confusion with leukoplakia or syphilis of 
 
134 PAPULES AND PAPULAR DERMATOSES 
 
 the month. This localization of lichen is observed in about one- 
 half [one-third?] of the cases; it may be primary, preceding for a 
 long time the cutaneous eruption. Buccal lichen planus is painless 
 and the patients having it are invariably unaware of its existence. 
 The lesion consists either of opaline porcelain-like spots or of a 
 white network, closely resembling, although on a much larger scale, 
 the net which has been described in the typical papules of the skin. 
 
 On the genital organs, notably on the glans and prepuce, umbil- 
 icated papules and often circinate or annular forms are observed. 
 Vulvar, urethral and anal lichen planus have also been reported. 
 
 The ordinary course of lichen planus is sluggish. The eruption 
 appears insidiously, progresses during a few months, then persists 
 a variable time, sometimes for years, without changing. Generally, 
 however, this course is interrupted by subacute attacks, for instance 
 on the occasion of physical or emotional disturbances; the lesions 
 multiply, new regions are invaded, there is a recurrence of itching. 
 Retrogression is slow and imperceptible, the papules and patches 
 usually leave very persistent and suggestive pigmented spots. 
 
 The name acute lichen is used for a variety which takes a rapid 
 course. In these cases, an extensive eruption suddenly appears 
 over large surfaces of the trunk or the limbs. It consists of a 
 diffuse redness, with swelling of the skin and some desquamation, 
 on which can be made out minute incipient papules, the size of a 
 needle-point; sometimes they can be seen only with a lens and 
 when the skin is stretched. Examination by biopsy shows that 
 even the smallest papules possess the characteristic structure. The 
 eruption may be accompanied by some systemic disturbance. More 
 particularly in acute lichen, although only in exceptional cases, 
 a few ephemeral bulla? (lichen ruber bullosus), or sometimes acu- 
 minate lesions may be seen. Acute lichen subsides in a month or 
 two or it may pass into the chronic form. 
 
 Pathological Anatomy. — The structure of the lichen planus papule 
 is characteristic. The Malpighian body, from being at first con- 
 siderably hypertrophied (acanthosis) is less markedly so later on, 
 when the corneal layer has thickened at its expense. The granular 
 layer is preserved and even hypertrophied (granulosis), but the 
 keratohyalin is unevenly distributed in different points of the same 
 papule. It gives rise to the pathognomonic network of the white 
 or opaline streaks. The horny layer is thickened, coherent, loaded 
 with fat and formed by normal non-nucleated cells (keratosis); in 
 long-standing papules, nucleated corneal cells may be found, and 
 corneal globes are sometimes seen at the orifice of a few follicles. 
 
 The papillae are not elongated, but broadened into cupolas and 
 are often slanting. The boundary line of the derma and the epi- 
 dermis is therefore very irregular; it is usually somewhat obliterated 
 
LICHEN PLANUS 
 
 135 
 
 in places (Fig. 34, 6r). Sabouraud (1910) has shown that small 
 serous effusions may be encountered in the basal layer of the epi- 
 dermis, as well as a few giant cells of epithelial origin, either in 
 the basal layer or much more rarely in the subjacent infiltration. 
 
 The papillary body contains a diffuse infiltration composed of 
 small round cells; some of these and sometimes a few Malpighian 
 cells, may have undergone colloid degeneration. The lower limit 
 of this infiltration is always markedly distinct; beyond it, only a 
 few perivascular cuffs are demonstrable. 
 
 The papule is accordingly of the mixed, epidermo-dermic type. 
 
 I have described strictly analogous lesions in lichen planus of 
 the mucous membranes; and in my opinion, the spots and white 
 network are referable to the abundant newformation of kerato- 
 hyaline. 
 
 Fig. 34. — Histology of a lichen planus papule. A, acanthosis; B, granulosis; C, 
 keratosis; D, colloid degeneration; E, diffuse infiltrate; F, cupola-shaped papilla; 
 G, boundary line of derma and epidermis. X 37. 
 
 Diagnosis. — The common error of mistaking lichen for a papular 
 syphilide is not justified by any real resemblance. 
 
 Secondary lichenizations have diffuse outlines; glistening facets 
 may be found, but no papules as distinct as those of lichen planus; 
 and the opaline streaks are absent. Real difficulties may arise, 
 however, in some cases. 
 
 Pruriginous eczema in children is not infrequently associated with 
 small glistening papules. An observer who is not aware of this 
 possibility may mistake the condition for an eczematized lichen 
 planus or a diffuse prurigo; these papules are generally ephemeral. 
 
 Circumscribed prurigo (the chronic lichen simplex of Vidal) 
 occasionally very closely simulates lichen planus. Its papules are 
 hemispherical, instead of plane, less glistening and are devoid 
 of white streaks. 
 
 Porokeratosis of Mibelli, which is very rare, and the palmar and 
 plantar keratoderma and porokeratosis may cause serious difficul- 
 ties in the differential diagnosis from lichen planus of the same 
 regions. 
 
(.36 PAPULES AND PAPULAR DERMATOSES 
 
 There is a form of lichen scrofulosorum with Mat and glistening 
 papules, but without an opaline network; it is very rare. 
 
 In lichenoid parapsoriasis, the analogy of the lesions with those 
 of lichen planus is merely temporary; the course suffices for the 
 differentiation. 
 
 Acute lichen may be suggestive of erythroderma. 
 
 Etiology and Character. — Lichen planus is a disease of adult life, 
 more common in men than in women. [According to the American 
 Dermatological Association's statistics, it is seen once in a little 
 more than 200 cases of skin diseases.] 
 
 It occurs so frequently in nervous, irritable individuals, in con- 
 nection with a psychic shock, violent emotions, grief and worry, 
 accompanied by insomnia, nervous excitement, neuralgias, etc., as 
 to suggest its interpretation as the cutaneous manifestation of a 
 nervous disturbance. This theory cannot be proved. I have not 
 found lichen planus to manifest itself with special frequency during 
 the war. [The nervous disturbances may well be the effect rather 
 than the cause of this dermatosis.] 
 
 Jacquet and others have advanced the view that the eruption 
 is always secondary to scratching. It is perfectly true that a 
 patient suffering from lichen planus will sometimes present a linear 
 -erics of papules originating in a nail or pin scratch. Scratching 
 an affected region may therefore be held responsible for the onset 
 of a more profuse eruption. But on the other hand, itching is 
 often entirely absent and lichen of the mucous membranes is never 
 associated with any pruritic sensation. 
 
 The nervous factor is sometimes absent. Apparently contagious 
 cases have been reported, as well as other, more numerous, cases of 
 familial lichen planus. 
 
 The pathological anatomy would conform very well with the 
 microbic theory; but this rests on no really conclusive fact. The 
 question of etiology must therefore be left open. 
 
 Treatment.— General Treatment. — General treatment ranks first 
 in order of importance, being that of nervousness and pruritus. 
 The dietetic regimen, general hygiene, and so forth, must be regu- 
 lated according to the schedule given elsewhere. (See Therapeutic 
 Notes, Section 12. J 
 
 Hydrotherapy particularly the sedative lukewarm douches 
 advocated by Jacquet as by themselves alone sufficient for the 
 cure of obstinate cases of lichen planus- is often very efficacious. 
 Various hot springs are of value. 
 
 Electricity, in the form of static baths and especially high-fre- 
 quency currents, has yielded remarkable results in my experience. 
 Radiotherapy is applicable to localized eruptions. 
 
 Thibierge and Kavaut have observed rapid cures following 
 
LICHEN PLANUS 137 
 
 spinal puncture and have recommended this procedure in the 
 treatment of the disease; its efficacy is not reliable. 
 
 Among internal medicinal agents, arsenic is regarded as a specific 
 by the Vienna School and by a number of dermatologists. It is 
 prescribed in various forms and in large doses, but at intervals. 
 Sodium arsenite, for example, may be given in doses of 4 mg. 
 daily to begin with, increasing by 2 mg. daily until 12 to 15 mg. are 
 reached, and then diminishing. Or from 5 to 12 mg. of potassium 
 or sodium arsenite may be administered in daily injections. [Several 
 American observers have reported good results from the internal 
 administration of mercury.] 
 
 Under these conditions [when the treatment is prolonged] arsenical 
 poisoning may be expected; aside from digestive disturbances, 
 cramps and formication, there is danger of palmar and plantar 
 hyperkeratosis, or of greatly increased pigmentation of the spots, 
 or even the development of melanoderma. Intravenous injections 
 of arsenobenzol, while not possessing the same disadvantages, 
 cannot be unconditionally recommended. 
 
 Antipyrin, nerve tonics, salicylates, etc., are unreliable. 
 
 Local Treatment. — Local treatment consists of various topical 
 applications, pastes, salves and plasters made with calomel, yellow 
 oxide, chrysarobin, even with sublimate; to the mercurials may be 
 added phenol, menthol, tartaric or salicylic acids. Collodium with 
 oil of cade is sometimes very successful in discrete eruptions. Appli- 
 cations of potassium permanganate, in fairly strong solution, have 
 been recommended by Hallopeau, even against buccal lichen 
 planus, the treatment of which is extremely unsatisfactory. 
 
 Atypical Forms of Lichen Planus. — Of the following dermatoses, 
 some are varieties of Wilson's lichen, whereas others are probably 
 independent of the same and will ultimately come to be classified 
 in other nosographical groups. 
 
 Atrophic or Sclerotic Lichen Planus, studied by Hallopeau and 
 myself in 1887, is a legitimate lichen planus, the plane papules 
 of which become depressed in the center which becomes cicatricial; 
 they extend slowly at the periphery and become confluent with the 
 neighboring lesions. The resulting atrophic spots are white or 
 nacreous, rounded or poly cyclical. On their thinned epidermal 
 lining corneal granules are sometimes found lying in the sweat 
 and follicular orifices. These white spots may attain the size of a 
 silver dollar. 
 
 Histology shows that a sclerotic band has become interposed 
 between the epidermis and the infiltration. When the process is 
 checked, the papular border and the rose-colored areola disappear 
 but the cicatrix is indelible (Fig. 35). 
 
 The wrists, forearms, neck, breasts, abdomen and sometimes the 
 
138 
 
 PAPULES AXD PAPULAR DERMATOSES 
 
 thighs are the regions in which this variety of lichen has been 
 especially observed. Zumbusch has described it under the new 
 name of lichen albus, which was not needed.. 
 
 Fig. 35. — Lichen planus atrophicus on the nape of the neck in a woman aged fifty- 
 three years. 
 
 1 [G. 36, — Lichen obtusus vulgaris of the leg. 
 
 Lichen Nitidus of Pinkus is an eruption of small, flat, glistening, 
 sometimes slightly dusky papules, which never becomes confluent 
 and causes no itching. It is almost invariably localized on the penis, 
 but may be generalized, persisting unchanged for years. Ilisto- 
 
LICHEN PLANUS 
 
 139 
 
 logical sections show a tuberculoid nodule, rich in giant cells, lying 
 directly under the epidermis. 
 
 Lichen Obtusus. — The name of lichen obtusus has been applied 
 to various imperfectly understood eruptions with hemispherical 
 papules. Lichen planus obtusus of Unna is characterized by dry 
 scattered elevations, the size of a pea, brownish or purplish in color, 
 not scaly, and only slightly pruritic. 
 
 Fig. 37. — Lichen corneus hypertrophieus of the leg, in a man aged sixty-two years, 
 who simultaneously presented lichen planus on the back of the hands. 
 
 Lichen Planus Moniliformis of Kaposi seems to be a rare variety of 
 lichen planus, with large hemispherical papules, arranged in strands 
 [like a string of beads]. 
 
 Lichen Obtusus Vulgaris consists of large, faintly pinkish or brown- 
 ish papules, usually grouped in a single region and even confluent; 
 I have observed it especially on the anterior surface of the legs 
 (Fig. 36). It is more or less pruritic and runs a very protracted 
 course. The elevations are often covered with a horny coat. 
 
1 10 PAPULES AND PAPULAR DERMATOSES 
 
 The relations between this form and lichen planus are doubtful; 
 it is often confused with the following: 
 
 Hypertrophic Lichen Corneus or Lichen Verrucosus, consists of pink- 
 ish or red warty protuberances, usually covered with very adherent 
 brownish or chalky horny masses. They have the dimensions of 
 a pea to those of nummular patches. They are disseminated, or 
 more frequently grouped, or even confluent, in a roughly outlined 
 network. Their surface may have an alveolar appearance, pro- 
 duced by numerous corneal cones dipping into the cutaneous pores. 
 Itching is variable, intermittent and inclined to be nocturnal. 
 
 The seat of predilection of the eruption is on the legs, but it 
 may also occupy the elbows, the Hanks and buttocks, etc. The 
 microscope reveals a well-marked total epidermic hypertrophy and 
 a considerable elongation of the papilla*. 
 
 I have repeatedly demonstrated the coincidence of this lichen 
 verrucosus corneus with typical lichen planus, or with buccal lichen 
 planus, I have also seen lichen corneus developing on oozing or 
 crusted eczematous foci (Fig. 37). 
 
 It is, therefore, probable that various dermatoses may terminate 
 in the clinical picture of lichen corneus hypertrophicus, eczemas, 
 prurigos and lichens appearing among these affections. The 
 course is very slow and the disease is extremely obstinate. 
 
 The treatment of the atrophic and obtuse lichens does not differ 
 from that of lichen planus. 
 
 Hypertrophic Horny Lichen requires vigorous washing with soap, 
 applications of caoutchouc or moist dressings for cleansing purposes, 
 followed by strong reducing agents, notably chrysarobin. It is 
 sometimes necessary to resort to the curette or the thermocautery. 
 Hydrotherapy and radiotherapy are very valuable measures in 
 these cases. 
 
 PAPULES OF PRURIGO. 
 
 Prurigo represents one of the most confused problems in derma- 
 tology. The simplest way of settling it consists in calling prurigo 
 all primary itching which is accompanied by certain special cuta- 
 neous reactions, namely the papules of prurigo and lichenization. 
 
 Pruritus and prurigo, as disease conditions, will be described 
 further on (XXIV). 
 
 Among their eruptive manifestations, those which assume the 
 form of papules arc the only ones here to be discussed; it is desirable 
 to consider them in connection with lichen papules, with which 
 they are always liable to be confused. 
 
 There exist two forms of papules in the prurigos: the papule 
 of strophulus or acute prurigo and the papule of genuine or chronic 
 prurigo. 
 
PAPULES OF PRURIGO 141 
 
 The Papule of Strophulus. — The papule of strophulus is an 
 elevation of the size of a large pin-head, lenticular shape, dusky 
 or pinkish color and firm consistence (Fig. 148). Careful examina- 
 tion shows it to be always centered by a yellowish point which is 
 really a minute vesicle or tiny crust. It originates almost invari- 
 ably in the center of a more or less transitory urticarial spot. Dur- 
 ing the first hours, it is often necessary to stretch the skin at the 
 site of this spot in order to bring out the papule hidden by it. The 
 papule will appear like a droplet of wax; on palpation a firm round 
 induration is felt. 
 
 At the end of four to twelve hours, the urticarial spot disappears 
 and the papule remains behind. It persists from eight to fifteen 
 days; the crust which crowns it is demonstrable nearly to the end. 
 When this crust has been torn away by scratching, it becomes 
 replaced by a bloody crust. In disappearing, the papule often 
 leaves a not very persistent pigmented spot behind it. 
 
 In exceptional cases, smaller papules are met with, lasting only 
 three to four days; larger reddish papules, the size of a lentil; 
 papulo-vesicles with distinct vesicles, sometimes attaining the size 
 of a pea, umbilicated or not, with clear or turbid contents. 
 
 Histological examination shows that the strophulus papule is 
 dermo-epidermic and consists of papillary edema and vascular 
 dilatation with a diffuse infiltration of leukocytes; edema of the 
 mucous body; a lenticular disk of colloid appearance situated 
 directly under the horny layer and composed of parakeratotic 
 corneal cells and edematous desiccated epidermic cells; spongiosis 
 is regularly present beneath and on the borders of this disk. This 
 structure is characteristic. 
 
 The papule of strophulus, with its associated urticaria, is the 
 special eruptive lesion of acute prurigo simplex, to which its old 
 name of strophulus is advantageously reapplied. It is also met with 
 rather frequently, but not invariably, in the first stage of Hebra's 
 prurigo. 
 
 The Papule of Prurigo. — The papule of prurigo has the following 
 characteristics : Its volume usually varies between that of a millet 
 seed and that of a large pea; its form is more or less hemispherical, 
 rarely flat; its rounded, sometimes ovaloid contours are not quite 
 distinctly outlined; its color is variable, sometimes of the same 
 shade as the normal skin of the region, or it may have a more or 
 less bright pink, darkened, yellowish or brownish hue; its consist- 
 ence is more or less firm, never soft; its surface is either very smooth, 
 almost glistening, or more often scaly, not infrequently excoriated 
 and covered with a bloody crust. Briefly, it presents a considerable 
 objective resemblance to the papule of lichen obtusus (Fig. 36). 
 
 According to various authors, this papule may sometimes become 
 
142 PAPULES AND PAPULAR DERMATOSES 
 
 crowned with an eczematoid vesicle, or it may undergo suppura- 
 tion; I believe these are superadded lesions due to traumatism and 
 infection. 
 
 The structure of the prurigo papule can be defined in a few words; 
 it consists of localized acanthosis; edema and infiltration are 
 absent or slightly marked; Jadassohn, however, speaks of the 
 frequent presence of large numbers of eosinophile cells in the 
 derma; Leloir and Tavern ier have described an intra-malpighian 
 cavity containing clear fluid and few leukocytes, said to be char- 
 acteristic of Hebra's prurigo; I have never observed it. 
 
 The prurigo papule is regularly met with in Hebra's prurigo in 
 its second stage, in the form of a scattered eruption; it may reach 
 the size of a hazel-nut in prurigo ferox (see Fig. 149). It is some- 
 times observed in diffuse prurigo vulgaris, but almost invariably 
 in circumscribed prurigo (chronic lichen simplex of Yidal). It 
 must not be confused either with the papule of strophulus or with 
 the papule of lichen planus and especially not, as is frequently done, 
 with excoriated follicular papules which will be discussed in describ- 
 ing the other cutaneous manifestations of pruritus and prurigo 
 (p. 487). 
 
 PAPULAR SYPHILIDES. 
 
 Papular eruptions are among the common manifestations of the 
 secondary stage of syphilis and their recognition is accordingly 
 important. 
 
 They are classified, according to the dimensions of the lesions, 
 into syphilides with small papules, which will be described with 
 the folliculoses (for they are always peripilar); syphilides with 
 medium-sized lenticular papules and syphilides with large papules, 
 or papulo-nummular syphilides. 
 
 Lenticular papular syphilides are perfectly round, disk-shaped 
 protuberances, of a pinkish (later red or ham-colored) rarely cop- 
 pery hue, firm to the touch and giving the sensation of a sharply 
 circumscribed dermic infiltration. 
 
 On their surface the epidermis is raised in a fine glistening layer; 
 when this is detached, a scaly border is left, known as Biett's 
 collar; the last-named sign may be absent and is moreover not 
 absolutely pathognomonic. Not uncommonly, there is more 
 profuse desquamation and the lesion may then be named papulo- 
 squamous syphilide. 
 
 Lenticular syphilides are common, sometimes following the 
 roseola through a papular transformation of the spots (papular 
 roseola), or becoming intermingled with the latter (erythemato- 
 papular syphilides), or they may constitute a syphilitic eruption 
 
PAPULAR SYPHILIDES 143 
 
 by themselves. These attacks have a tendency to recur, especially 
 in the course of the first year, in insufficiently treated patients. 
 
 The eruption is usually abundant, symmetrical, very irregularly 
 scattered over the trunk and limbs, even on the face and on the 
 palmar and plantar surfaces. It is often associated with mucous 
 patches, alopecia, sometimes with pigmented syphilides, nodular 
 syphilides or other complicated eruptions. 
 
 Fig. 38. — Eruption of lenticular papular syphilides, mixed with a few follicular 
 syphilides. 
 
 It lasts from ten to thirty days when treated, from two to three 
 months in the absence of specific treatment. The papules leave 
 in their place reddish, sometimes pigmented hyperchromic spots, 
 especially on the lower limbs, very persistent and most distressing 
 to the patients. Such cases were described by Fournier under the 
 name of syphilides nigricantes . The occurrence of atrophic spots 
 or macules has also been observed (Fig. 38). 
 
 Several deformities or irregularities of the lenticular papules and 
 papulo-squamous syphilides are known to occur. They become 
 
144 
 
 PAPULES AND PAPULAR DERMATOSES 
 
 papulo-erosive, under the influence of maceration, in the axillary, 
 inguinal, intergluteal folds, at the umbilicus and around the geni- 
 tals. This aspect is frequently seen in congenitally syphilitic 
 infants, on the buttocks, the back, the neck, the genital regions and 
 sometimes involves the entire lower limits. 
 
 In the seborrheal regions papular syphilides are arranged in 
 certain eases in manunillate, circinate or irregular-shaped patches, 
 covered with greasy crusts, these are designated as seborrheal 
 syphilides and on the forehead constitute the corona veneris; they 
 are very resistant to treatment, unless appropriate topical agents 
 are employed together with the specific medication. 
 
 The psoriatiform, papulo-crusted and fungoid varieties of the 
 papular syphilides have been mentioned already or will be discussed 
 later. 
 
 Fig. 39.— Arcif 
 
 Aii interesting (because absolutely pathognomonic) form is that 
 of the papulo-drcinate or arcif orm [or annular] syphilide (Fig. 39). 
 This is observed only in the course of the first year and in young 
 women who have already been treated. [It is not uncommon in 
 the negro race in both sexes.] It presents the appearance of 
 regular rings, graceful arcades or complicated circulations, on the 
 chin, around the lips and nostrils, or sometimes on the vulva. 
 The circles are continuous or formed by small fine-scaly papules 
 having a yellowish-pink color. 
 
 Papulo-nummular syphilides are discoid or oval prominences, 
 from 1 to 3 cm. in diameter; on account of their form and their 
 ordinarily oozing or crusted surface, they have been named cuta- 
 neous patches (Bazin), syphilitic patches (Legendre), or mucous 
 patches of the skin. 
 
LICHEN SCROFULOSORUM 145 
 
 These syphilides are extremely common in the ano-genital region, 
 but may develop in any skin fold. They are also met with in 
 association with a papulo-lenticular eruption, on the neck, the face, 
 the shoulders, etc., but are not numerous there. They might be 
 confused with iodide eruptions, but these are pustular and grow 
 much more rapidly. 
 
 All these papular syphilides have a nearly identical structure (Fig. 
 31); they are composed of an intradermic plasma-cell infiltration 
 and differ among themselves only by the lesions of the epidermis. 
 
 The diagnosis of papular syphilides is usually easy. Lichen 
 planus, psoriasis and parapsoriasis differ from these syphilides by 
 the features of their own lesions. The papules of the diffuse and 
 circumscribed prurigos are distinguished by the very active pruri- 
 tus by which they are accompanied. Hydradenomas of the thorax, 
 which are very rare, have an analogous appearance but their 
 duration is indefinite and their localization is strictly limited. 
 
 Papulo-necrotic tuberculides may give rise to serious diagnostic 
 difficulties, although it is known that they chiefly affect the limbs, 
 that their development is successive and usually slow, that they 
 become hollowed out by ulceration and leave a cicatrix. In a 
 given case, however, the decision may have to be based upon the 
 coexistence of other specific manifestations, biopsy and serodiagnosis. 
 The diagnosis of posterosive syphiloids in the newborn is still 
 more difficult. Mistakes are common and seriously detrimental to 
 infants wrongfully suspected of syphilis. The presence of other 
 manifestations of congenital syphilis, the condition of the parents 
 and the course of the eruption, permit a positive diagnosis in some 
 cases. The Wassermann reaction of the child and its mother must 
 be determined in doubtful cases and sometimes biopsy and a search 
 for spirochetes is called for. 
 
 LICHEN SCROFULOSORUM. 
 
 Lichen scrofulosorum is a papular eruption resembling lichen in 
 its clinical appearance, but in its nature related to the tuberculides 
 or attenuated tuberculoses of the skin. 
 
 It will be seen further on that the tuberculides constitute a group 
 of dermatoses of identical etiology, but extremely polymorphous 
 objective characters. The most frequent and distinct forms have 
 received special names, the others are considered as intermediary 
 forms. 
 
 My description deals with the most pronounced type of the 
 papular tuberculides; but it must be emphasized from the start 
 10 
 
146 
 
 PAPULES AND PAPVLAli DERMATOSES 
 
 that there exist numerous atypical and less distinctly characterized 
 varieties. 
 
 Lichen scrofulosum of Hebra, the papular scrofulide of Bazin — 
 a better name for vhich would be lichenoid tuberculide — presents 
 the following appearance: 
 
 An eruption of small papules, of the average size of a pin-head 
 slightly prominent, flattened, polygonal, of a pale yellow or more 
 rarely a dusky red color, of rather soft consistence, a surface smooth 
 and glistening or more commonly covered by a slightly adherent 
 scaly layer, such is the typical form (resembling the papule of 
 lichen planus) which is, however, not the most frequent. 
 
 These papules are almost invariably grouped in more or less 
 numerous nummular plaques or in patches, rings, or semicircles; 
 also as an irregular network, the interpapular areas remaining 
 normal. 
 
 The eruptions usually occur on the trunk, especially the flanks and 
 loins, but may spread to the limbs and exceptionally to the face. 
 It appears insidiously, almost without pruritus, persists during 
 several months and then disappears leaving no trace of any kind. 
 Sometimes recurrences develop in attacks during several years. 
 
 FlG. 40. — Lichen scrofulosorum, acuminate variety. (This group of papules 
 suddenly appeared on the back of a young woman suffering from lupus, shortly after 
 an injection of tuberculin). 
 
 There are numerous varieties, and the following forms may be 
 found associated with the flat and glistening papules, in the 
 same or in different regions, or constituting by themselves the 
 entire eruption: conical or acuminated papules, of a rose-red color 
 (Fig. 40) and centered over a follicle the hair of which may be 
 broken off flush with the orifice; in other cases, conical papules 
 crowned by a vesico-pustule, of the type of acne cachecticorum ; 
 or again, confluent lesions may form scaly polygonal disks, of a 
 purplish or brownish-red color, slightly infiltrated, not very promi- 
 nent, which resemble psoriasis or some of the eczematides; and 
 finally, the eruption may present a mixture of follicular papules and 
 
LICHEN SCROFULOSORUM 147 
 
 patches dotted with acuminate lesions suggestive of pityriasis rubra 
 pilaris or lichen spinulosis. 
 
 Under the heading of lichen scrofulosorum there should also be 
 grouped, according to Boeck, as deformed or attenuated varieties: 
 his disseminated papulosquamous tuberculide; his eczema scrofulo- 
 soram, characterized by crusted and oozing patches with an infiltrated 
 base constantly recurring at the same points; certain forms of 
 pityriasis simplex of the face in children, arranged in circumscribed, 
 red, fine-scaling patches and accompanied by large cervical glan- 
 dular swellings. 
 
 Lichen scrofulosorum is observed at all ages, but occurs by predi- 
 lection in children and youthful individuals suffering from glandular 
 or bony tuberculosis or from sluggish visceral tubercular lesions. It 
 has been known to follow acute diseases, such as measles, etc. 
 
 The papules are formed, as was first shown by Jacobi and Sack, 
 by a dermic infiltration having almost invariably the constitution 
 of characteristic tubercular follicles, with giant cells, but with a 
 slight tendency to caseous degeneration ; these tubercles are situated 
 in the papillary body or around a pilo-sebaceous follicle. 
 
 Jacobi, Sack and Wolff succeeded in finding the Koch bacillus in 
 their specimens and in a few of their cases guinea-pig inoculation 
 proved positive. 
 
 A general and local tuberculin reaction is practically constant; 
 Jadassohn obtained a positive reaction in 14 out of 16 cases. 
 Schoeninger, Buzzi and myself have observed the appearance of 
 lichen scrofulosorum immediately after injections of tuberculin, 
 which undoubtedly merely served to bring out latent lesions (Jadas- 
 sohn, 1896). 
 
 The diagnosis of lichen scrofulosorum may present very con- 
 siderable difficulties. In view of its habitual polymorphism, it is 
 advisable to examine not only one eruptive group but the erup- 
 tion as a whole ; thereby guarding against confusion with the 
 eczematides, lichen planus, acne cornea, abortive forms of pityriasis 
 rubra pilaris, etc. 
 
 The differential diagnosis from the follicular lichenoid syphilides 
 is sometimes almost impossible, even on examination by biopsy. 
 The Wassermann reaction is of great help in these cases. 
 
 The treatment is that of tuberculosis in general: fresh air, sun- 
 light, cod-liver oil, calcium compounds and arsenic; tuberculin in 
 very minute doses or novarsenobenzol may lead to rapid improve- 
 ment. Locally weak reducing agents and cod-liver oil ointments 
 have been recommended. 
 
CHAPTER VIII. 
 VESICLES AND VESICULAR DERMATOSES. 
 
 Vesicles are small circumscribed elevations of the epidermis 
 containing a clear fluid. Their size varies from that of a pin-head to 
 that of a pea; their form is hemispherical, or sometimes acuminate 
 or umbilicated; their outline is round; or, as the result of confluence 
 they may assume an angular or polycyclical configuration. 
 
 The contents of the vesicles are fluid and transparent like water 
 or yellowish and serous. It is sometimes necessary to prick the 
 roof with a needle in order to demonstrate the presence of the fluid 
 and its properties. The contents are apt to become cloudy or turbid 
 after a time; sometimes they are hemorrhagic from the start. 
 
 As the result of desiccation, the vesicles are transformed into 
 crusts whose origin is indicated by their shape and arrangement. 
 
 On the mucosa? and semimucosse, as well as in regions where skin 
 rests against skin, the vesicles rupture very readily leaving red 
 erosions or often diphtheroid lesions of rounded or polycyclic 
 contours. 
 
 Modes of Formation of Vesicles. — They always result from an 
 accumulation of plasma in the epidermis. Vesiculation may occur 
 in three different ways which are, however, frequently combined. 
 
 In the first, or parenchymatous vesiculation, the fluid accumulates 
 first in the interior of the Malpighian cells and the resulting uni- 
 cellular vesicles become confluent with each other. This so-called 
 "alteration cavitaire" of Leloir predominates in smallpox, vaccinia, 
 etc. 
 
 In a second type, or interstitial vesiculation, the edema is inter- 
 cellular, compressing and stretching the Malpighian cells which 
 are drawn out into a net, the threads of which finally rupture, pro- 
 ducing the spongioid state of Unna, the spongiosis of Besnier. The 
 vesicles of eczema are produced in this way (Fig. 5). 
 
 In a third type, the edema is likewise intercellular, but the cells 
 become globular, are detached from each other and float in the 
 fluid, undergoiag a cloudy or fibrinous degeneration, sometimes 
 becoming hypertrophied with multiplication of their nuclei. This 
 is the ballooning alteration of Unna, which predominates in the vesi- 
 cles of varicella, zona (Fig. 41), herpes, etc. 
 
 Whatever the mechanism of their production, vesicles always 
 
MODES OF FORMATION OF VESICLES 
 
 149 
 
 result from an inflammatory process and constitute acute eruptions 
 on a hyperemic base. 
 
 Vesicles differ from bullce not only by their usually smaller 
 volume but also by their mode of formation. In contradistinction 
 to bullae, they are frequently multilocular, at least at their inception. 
 
 They differ from serous cysts, notable from the hydrocystomas 
 and lymphatic varices which may simulate them, by the intra- 
 epidermic seat of their fluid ; they can be opened by puncture without 
 causing hemorrhage. 
 
 Fig. 41. — Section of a zona-vesicle on the tenth day. Vesiculation through bal- 
 looning alteration ; in the center of the vesicle all the cells of the rete are degenerated 
 and the papillae are exposed. In the cutis an abundant infiltration of lymphoid 
 cells is seen. X 50. 
 
 Vesicular Dermatoses. — Vesiculation is observed in the eruptive 
 fevers, variola, varicella and vaccinia, for which the reader is 
 referred to text-books of general medicine. 
 
 In eczema from any cause, vesiculation is very common; it has 
 even been considered as characteristic of the eczematous process. 
 It may be absent, however, and at any rate represents merely 
 a stage or episode of eczema, which was discussed in a chapter bv 
 itself (IV). 
 
 The vesicles of cutaneous trichophytosis, formerly called herpes 
 circinatus seem to me to be of eczematous character; they will be 
 mentioned in the chapter on parasitic dermatoses, as will also those 
 which complicate scabies. 
 
 Sudamina, notwithstanding their small size, are not vesicles but 
 minute subcorneal bullae; they will be discussed together with the 
 hidroses. 
 
 In recurrent polymorphous pemphigus, commonly known as 
 dermatitis herpetiformis of Duhring, genuine vesicles are found at 
 the same time as real bulla?; this affection is in every respect related 
 to the bullous dermatoses. 
 
 The eruption of strophulus is usually papular; it is exceptional for 
 the microscopical vesicle which crowns its papules to assume a 
 
L50 VESICLES AND VESICULAR DERMATOSES 
 
 development rendering it visible to the naked eye; however, certain 
 very rare eases have simulated varicella. This affection belongs to 
 the group of the prurigos. 
 
 In this chapter there remains to be studied only herpes, zona 
 and the zosteriform eruptions. These are purely and exclusively 
 vesicular eruptive syndromes. 
 
 HERPES. 
 
 Herpes is an acute eruption of a cluster of vesicles, varying in 
 number and originating on an erythematous base, situated any- 
 where, although having a predilection for the face, around the mouth 
 and the nose and for the genital region. The affection is extremely 
 common and known to the laity under the name of "fever blister." 
 
 The word herpes formerly had a much more restricted significance. 
 The terms herpetism, herpetides, no longer possess any accurate 
 meaning. The name of herpes is still used for some dermatoses of 
 very variable kinds, such as herpes circinatus, herpes gestationis, 
 herpes iris, herpes cretaceus, etc., which are in no way related to 
 genuine herpes. Zona is also known as herpes zoster. 
 
 Symptoms. — Frequently preceded a few hours by shooting pains 
 or a tense and burning sensation, herpes appears in the form of a 
 congestive edematous spot, which promptly becomes covered with 
 uniform vesicles, the size of a pin-head, with clear contents, from two 
 or three to several dozen in number. These vesicles lie very close 
 together and sometimes become confluent. They are rarely hemor- 
 rhagic. There may be several as if accidentally scattered groups. 
 The lymph glands are slightly enlarged. 
 
 The herpetic vesicles became turbid, then opaque and shrivel up, 
 forming yellow or brown crusts which become detached at the end 
 of eight to ten days, leaving a temporarily red spot, but never a 
 permanent scar. Herpes has a marked tendency to recurrence. 
 
 The seat of election of herpes is the lips, the nostrils, or any part 
 of the face; or the genital regions. Herpes is also not infrequently 
 seen on the lobes of the ears, the nipples and the mucous membranes; 
 but. is much rarer on the trunk and limbs. As a rule, only one of 
 these regions is affected at the same time. In the course of the War, 
 however, I was enabled to observe in young soldiers recently vac- 
 cinated against typhoid fever, profuse eruptions of herpes occupying 
 simultaneously the forehead, the nose, both lips, the mouth, the 
 chin, the ears, the neck, and in one instance one of the upper extremi- 
 ties; the condition being suggestive of so-called multiple zona. 
 
 Herpes genitalis [or progenitalis] is especially noteworthy on 
 account of the liability to misinterpretation. Li men, it occupies 
 the balano-preputial sulcus, the glans, the prepuce, or more rarely 
 
HERPBS 
 
 151 
 
 the meatus. On the parts covered by the clothing, it is rapidly 
 transformed into erosions. These are very superficial, isolated or 
 confluent, round or polycyclic and microcyclic, red or diphtheroid; 
 some fluid can be squeezed out of them and they are slightly painful. 
 Herpes is not indurated at the base, provided it is not improperly 
 treated or abused, and heals in at most eight or ten days. [On the 
 glans a certain degree of induration is common and must be con- 
 sidered in making a diagnosis.] When the lesion has been cauterized 
 or treated with irritants or antiseptics (silver nitrate, sublimate, 
 tincture of iodin, aristol, etc.), always an improper procedure, it 
 may become indurated, associated with inflammatory phimosis and 
 painful swollen glands, ulcerate and last several weeks. In such cases 
 an immediate diagnosis is extremely difficult, sometimes impossible 
 before the inflammation has been relieved by soothing applications. 
 
 Fig. 42. — Profuse vulvar herpes, showing eruption of relatively moderate severity. 
 
 In women, herpes may occupy any portion of the vulva, presenting 
 the same features as in the male. It is met with exceptionally in the 
 vagina and the cervix uteri. 
 
 A profuse vulvar herpes sometimes occurs (Fig. 42) with some 
 fever, severe burning sensation, very marked local edema, extensive 
 patches covered with agglomerated or confluent vesicles, extending 
 from the vulva to the pubis, the internal surface of the thighs and 
 in the intergluteal fold. The macerated vesicles rapidly break, are 
 transformed into erosions or become covered with a diphtheroid 
 layer and secrete an offensive muco-purulent discharge. The glands 
 
L52 
 
 VESICLES AND VESICULAR DERMATOSES 
 
 are swollen and painful. The patient suffers great inconvenience and 
 is confined to bed. Healing takes place in fifteen or twenty days. 
 In some cases under my observation, the lesions became promi- 
 nent after epidermization had occurred, closely simulating papular 
 mucous patches. 
 
 Aside from the inconvenience and actual pain caused by it, genital 
 herpes is important on account of its tendency to recurrence and 
 because it prepares the soil for severe infections, soft chancres and 
 syphilis, in persons exposing themselves to risk of these diseases. 
 
 I K.. 13. Recurrent herpes of the che 
 taken two years previously by Brocq, is s 
 280; illustrating a more discrete eruption i 
 
 \ photograph of the same young girl, 
 n in his Traite de Dermatologie, ii, p. 
 
 ie same a iva . 
 
 It must also be kept in mind 
 or accompany the onset of 
 
 t an eruption of herpes may precede 
 /philitic chancre which may conse- 
 ain unrecognized for some length of 
 
 quently pass unobserved ot 
 time. 
 
 Herpes buecalis is less common, and is usually met with in connec- 
 tion with a profuse herpes of the lips or the face; it may occupy 
 the mucosa of the cheeks, the palate and the tongue. It is often 
 bilateral. Its vesicles are ephemeral. 
 
 Herpes of the pharynx seems to constitute one of the varieties of 
 herpetic angina, characterized by the abruptness of its onset, the 
 
HERPES 153 
 
 rapidly rising temperature, the severity of the local pain and the 
 marked general phenomena. Vesicles are occasionally found, but 
 more often polycyclic erosions, diphtheroid or not, which succeed 
 them. In doubtful cases, these erosions can be brought out, as on all 
 mucous membranes, by painting them with a weak solution of silver 
 nitrate, or better with a watery solution of chromic acid, 1 to 50 (L. 
 Jullien). The glands are usually swollen and painful. 
 
 Heroes conjunctivalis represents one of the forms of phlyctenular 
 conjunctivitis. 
 
 Recurrent herpes is that form which recurs, not accidentally and 
 at any point, but with a certain periodicity and in a practically 
 constant region. 
 
 Certain women have an eruption, either around the mouth or on 
 the genitals, at nearly every menstrual period (catamenial 
 herpes) . 
 
 Recurrent pro genital herpes, more particularly observed in men, 
 is considered by Diday and Doyon as related to an existing or 
 preceding venereal disease, especially soft chancre, gonorrhea and 
 syphilis. 
 
 Recurrent herpes of the face affects children and youthful indi- 
 viduals, returning periodically several times in the course of the 
 year on the same cheek, for ten years or more (Fig. 43). 
 
 Recurrent herpes of the buttock occurs in adults of both sexes, and 
 takes a more variable course. 
 
 Recurrent herpes of the mouth, pointed out by A. Fournier, the 
 distress of some old syphilitics, is referred either to remains of long- 
 cured specific lesions, or to abuse of mercury. 
 
 These various recurrent herpetes are not infrequently associated 
 with neuralgic pains, burning sensations, painful tension, glosso- 
 dynia, etc. 
 
 Etiology. — Herpes is observed at any age, but especially during 
 youth and maturity. Its causes are complex. There undoubtedly 
 exists a traumatic herpes; dentists, for example, are familiar with 
 the herpes developing around the mouth as a sequel of dental opera- 
 tions ; on the other hand, herpes of the vulva is not uncommon after 
 the first sexual intercourse. In both cases, the patients are much 
 inclined to suspect that they have been infected. 
 
 Many cases of recurrent herpes of the nose, the lips, etc., have 
 seemed to me to be related to a chronic irritation of the neighboring 
 cavities, dental caries, alveolitis, pulpitis, gingivitis, rhinopharyngitis, 
 sinus inflammations, otitis, etc. The nervous and probably reflex 
 character of many cases of herpes is therefore obvious. On the other 
 hand, there are cases of symptomatic herpes, in certain infections. 
 Herpes is known to be common in pneumonia, epidemic cerebro- 
 spinal meningitis, influenza, etc. Sometimes a high fever of a few 
 
154 VESICLES AND VESICULAR DERMATOSES 
 
 days' duration is terminated by an eruption of herpes, whence the 
 assumption of a herpetic fever. 
 
 A fairly well marked lymphocyte reaction of the cerebrospinal 
 fluid was noted by Ravaut and Darre in 21 of 2(5 cases of genital 
 herpes. 
 
 The disease is not contagious, nor can it be inoculated. Neverthe- 
 less, it is difficult to reject the idea that such an acute and severe 
 dermo-epidermic lesion often accompanied by glandular enlarge- 
 ment, constitutes an [infectious] inflammatory reaction rather than a 
 " trophic disturbance." 
 
 Treatment. — Herpes of the skin requires no active treatment, 
 it suffices to cover it with a bland powder; herpetic eruptions can 
 sometimes be aborted by dressings with absolute alcohol (90 per 
 cent), or with borated or camphorated alcohol; but failures are the 
 rule. Watery dressings and ointments are injurious, except in the 
 stage of complete desiccation. 
 
 Genital herpes must be gently treated; all irritant applications 
 involve the risk of changing its appearance and prolonging its dura- 
 tion. It suffices to wash or bathe it with lukewarm boiled or borax 
 water, or an infusion of bran; to powder it with talcum, or zinc 
 oxide, or bismuth subgallate. Touching with a drop of silver nitrate, 
 5 per cent. , is permitted and useful , but only when the diagnosis is posi- 
 tive and when the erosion fails to become covered with epidermis at 
 the end of a few days. [Inasmuch as a herpes may lodge a spirochetal 
 infection cauterization must in general be avoided.] Profuse herpes 
 of the vulva requires rest in bed ; the pain is relieved by poultices of 
 starch or cooling creams. 
 
 In the case of recurrent herpes, the essential point is the dis- 
 covery of the initial focus of chronic irritation and its removal. 
 Radiotherapy has repeatedly proved successful in my experience 
 in the cure of recurrent herpes of the buttock and the cheek. 
 
 ZONA. 
 
 Zona— or herpes zoster — is an acute eruption of vesicles, grouped 
 upon erythematous patches and ordinarily located along the dis- 
 tribution of a nerve, on only one side of the body. Its development 
 is approximately cyclic; it recurs but rarely. 
 
 Symptoms. — The eruption appears suddenly and is accidentally 
 discovered by the patient, or it may be preceded by prodromata 
 and accompanied by pains. 
 
 At the onset, nothing is seen but slightly elevated erythematous 
 patches, with a shagreened surface, of oval or irregular outlines, 
 from a single one to twenty in number, generally half a dozen, 
 separated by areas of healthy skin. At the end of a few hours, 
 
ZONA 155 
 
 at most a day, vesicles form first in the center, then on the entire 
 patch, and rapidly increase in size; they become tense, pearly, 
 uniform, from the size of a small to a large pin-head. They lie close 
 together, more rarely discrete, sometimes confluent. 
 
 Their fluid content becomes opalescent and turbid, even purulent, 
 by the third day, while at the same time the plaque fades and 
 flattens; desiccation begins from the fourth to fifth day and is com- 
 pleted by the eighth to twelfth day ; the crusts do not fall off until 
 the end of twelve to twenty davs. 
 
 Fig. 44. — Zona, on the tenth day of the eruption, occupying especially the cuta- 
 neous territory of the II and III left lumbar roots. Near the groin the patches are 
 confluent, the largest vesicles are hemorrhagic; numerous incomplete vesicles are also 
 seen. Near the knee the patches are isolated and typical. 
 
 The onset of the various patches is usually not simultaneous but 
 successive, in the course of two or three days, so that several stages 
 can be observed at the same time (Fig. 44). It frequently happens 
 that the eruption remains incomplete on certain patches, especially 
 the last to appear. From the start, or at the end of one or two 
 days, the fluid of the vesicles may assume a sanguinolent character, 
 constituting hemorrhagic zona. 
 
 It is rare for the vesicles to rupture. When they are opened in 
 the stage of suppuration, erosions or even fairly deep ulcerations 
 which heal slowly are found beneath them ; in this case, the eruption 
 leaves behind it, not only brownish macules, as is usual, but indelible 
 white scars with pigmented halos, sometimes cheloids, having a 
 characteristic distribution. This possibility must be mentioned to 
 the patient. 
 
 In cachectic or weak and senile individuals, genuine sloughing 
 
156 VESICLES AND VESICULAR DERMATOSES 
 
 scars may supervene, representing gangrenous zona, with a prognosis 
 sometimes serious. 
 
 The lymph glands corresponding to the territory of a zona are 
 nearly always enlarged, sometimes before the eruption appears. 
 Outside of this territory, the skiu is healthy. However, the possible 
 presence of aberrant vesicles, at a distance from the regional eruption, 
 has been pointed out by Tenneson. In a contribution to this sub- 
 ject (dedicated by me to Professor Barduzzi, of Livorno, in 1911) 
 it was noted that this observation is correct, but that, leaving out 
 of consideration the ordinary follicular inflammations and lesions 
 of miliary impetigo which may accompany the disease, genuine 
 aberrant vesicles in zona are relatively rare. [During an outbreak 
 of smallpox in New York in 1900 I observed several cases of gener- 
 alized herpes zoster in which the eruption was so extensive as to 
 require careful examination before varicella could be excluded.] 
 
 Pain is variable or may be absent. Almost invariably, however, 
 zona is either preceded for several days or even several weeks, or 
 accompanied, which is more common — or followed, by neuralgic 
 pains; these pains are continuous or paroxysmal and may assume 
 all possible forms, especially a severe burning sensation (hence the 
 popular name of St. Anthony's fire). The patches themselves are 
 sometimes anesthetic, it is claimed, but really almost invariably 
 hyperesthetic. The frequency, severity and duration of the pains 
 arc dependent upon the age of the patient; they are usually absent 
 in children, but in aged individuals may persist indefinitely, causing 
 extreme distress. 
 
 The eruption of zona may be preceded by general phenomena, 
 malaise, prostration, anorexia, with a transitory fever of 39° or -40° 
 [102°-104°]. In this case, the infectious behavior of the disease, 
 its sometimes epidemic and immunizing character, have caused it 
 to be likened to the eruptive fevers: the zoster fever of Landouzy and 
 Erb. The course of the disease may be described as nearly cyclical. 
 
 Among the localizations of zona, the most common is intercostal 
 zona, to which the disease owes its name. It covers the thorax or 
 the abdomen like a half-belt, without passing more than a few 
 millimeters at most beyond the median line. When it occupies the 
 territory of the first intercostal nerves, it follows the anastomotic 
 branch which the second intercostal nerve sends to the internal 
 brachial cutaneous nerve down the inner surface of the arm. 
 
 Cervical zona, which affects all or only some of the branches of 
 superficial cervical plexus, is likewise fairly common and the same 
 remark applies to lumbo-abdominal and genito-crural zona. Periph- 
 eral zonas, affecting the limbs, are more unusual. 
 
 Ophthalmic zona, corresponding to the superior branch of the 
 trigeminal nerve, is frequent and grave on account of its possible 
 
ZONA 157 
 
 sequelae. It presents frontal, palpebral, nasal, even pituitary 
 patches and in two-thirds of the cases gives rise to ocular lesions, 
 especially of the conjunctiva and cornea, lesions of the iris and 
 amblyopia being less common. Anesthesia of the cornea, corneal 
 perforation, irido-choroiditis and retinitis have been reported but 
 are very rare. Ophthalmic zona must not be confused at the start 
 with erysipelas or with keratoconjunctivitis from other causes. 
 
 Zonas of the mucous membranes, buccal, pharyngeal, etc., are of 
 very exceptional occurrence. 
 
 Zona is almost invariably unilateral and may occupy the territory 
 of a single nerve ; as. a rule, however, it spreads over the territory of 
 two or even three neighboring spinal roots, 
 
 Exceptionally, cases of double or bilateral, alternating, multiple, or 
 even generalized zona are encountered, such as a case reported by 
 Colombini in 1893. 
 
 Zona usually occurs only once in a life-time, but recurrences have 
 been noted in a few instances. So-called zonas with multiple recur- 
 rences belong to the zosteriform eruptions. 
 
 Etiology and Pathogenesis. — Zona affects all ages and both sexes 
 equally. It is slightly more common in the spring. The cause as 
 a rule remains entirely obscure. It has been observed to follow after 
 severe traumatisms, violent emotions; to occur in the course of 
 infections or general diseases, at the beginning or in the course of 
 tuberculosis (Leudet), pneumonia, pleurisy, syphilis, cerebrospinal 
 meningitis, mumps, carbon monoxid poisoning, arsenic medication 
 (Hutchinson, Neilson), diabetes, cancer, etc. 
 
 A number of circumstances indicate the infectious nature of zona, 
 at any rate in many cases. It is true that the disease is not con- 
 tagious, but it sometimes seems to be vaguely epidemic, in the sense 
 that several persons from the same environment are attacked at 
 intervals of a few days. It may be accompanied by general phe- 
 nomena; glandular swelling is usually present. Sabrazes and Mathis 
 have demonstrated the occurrence of hyperleukocytosis in the course 
 of zona, especially of the polynuclears and the eosinophiles. Finally, 
 an attack of zona usually confers immunity against another. The 
 pathogenic agent, however, has not as yet been demo istrated. 
 
 On the other hand, the relations of zona with the nervous system 
 are very striking, in the distribution of the eruption as well as the 
 associated neuralgias. I have seen a case of ophthalmic zona 
 following upon a severe contusion of the skull in an automobile 
 accident. Mme. Dioudonnat-Lempert devoted her thesis (1914) 
 to the study of cephalic or cervical zona of dental origin. Lesion 
 of a nerve branch in the course of a mercurial injection may give 
 rise to a cluster of zona-vesicles along its area of distribution. 
 Otic or para-auricular zona is not infrequently associated with 
 facial paralysis. 
 
i:»S VESICLES AND VESICULAR DERMATOSES 
 
 It lias recently been shown that in the course of syphilis, zona 
 may indicate a premature syphilitic meningitis which affects the 
 posterior roots, or it may precede tabes and general paralysis. Zona 
 is also sometimes encountered in syringomyelia, in dementia, 
 vertebral tuberculosis, cancer of the vertebra, etc. It is often accom- 
 panied by lymphocytosis of the cerebrospinal fluid ; in different cases, 
 this may exist prior to the eruption, coincide with it, or follow several 
 days later; or it may be entirely absent. More rarely, rigidity at 
 the nape of the neck, Kernig's sign, retardation of the pulse, head- 
 ache, etc., have been noted. 
 
 Numerous authors have demonstrated neuritis or degeneration 
 of the nerves in the affected area. However, as the distribution of 
 zona is far from being always in exact conformity with the distribu- 
 tion of the corresponding peripheral nerves, a lesion of the spinal 
 root and especially of the spinal ganglia is now held to be responsible. 
 Following Baerensprung and Charcot, various observers have 
 formed hemorrhagic, inflammatory, or degenerative lesions of the 
 spinal ganglia and the posterior roots in cases of zona; among these 
 writers, Head and Campbell must be specially mentioned (in 31 
 cases). Head in England, Brissaud, Achard, and others in France, 
 have endeavored to refer zona to a lesion of a spinal or metameric 
 segment. 
 
 At the present writing, the conclusion seems justified that the 
 metameric theory is probably true for certain cases; that the radicular 
 and ganglionic theory serves to explain the great majority of zonas, 
 as has been confirmed by anatomical findings; finally, that the 
 peripheral nervous theory applies to certain rare cases. 
 
 Granted that the necessary pathogenic condition of zona is a 
 lesion at some point in the course of neurons which supply the 
 affected territory, one is justified in admitting that this lesion can 
 be, in different eases: (1) of traumatic origin; (2) of toxic origin 
 (arsenic, CO); (3) of autotoxic origin (diabetes); (-1) finally, of 
 infectious character, either ordinary (tuberculosis, syphilis, pneu- 
 monia, grippe, etc.), or sometimes due to a specific germ. The 
 probable existence of this special microbic agent, which still remains 
 unknown, would serve to explain the epidemic character, the pro- 
 dromata, the febrile and infectious symptoms, the aberrant or dis- 
 seminated vesicles, the immunizing power against a new attack 
 which is characteristic of certain zonas and the so-called zoster- 
 fever of Landouzy and Erb, or idiopathic zona. 
 
 Jadassohn points out that according to this interpretation, zona 
 is the perfect type of a .syndrome with an always identical mor- 
 phology and pathogenesis, but a variable etiology. 
 
 Diagnosis. In typical cases, this is extremely easy; the eruption 
 of clustered vesicles, arranged in groups over one or more nerve 
 territories, unilateral, accompanied by pain and taking a cyclic 
 
ZONA 159 
 
 course, is absolutely characteristic. Doubt is possible only in incom- 
 plete or abortive cases. A careful examination will guard against 
 confusion with erysipelas, eczema, or polymorphous erythema. The 
 differential diagnosis may occasionally be difficult from herpes and 
 the zosteriform eruptions. 
 
 Herpes is identical as regards the eruptive lesions, but is suffi- 
 ciently characterized by its site, its frequently bilateral appearance, 
 and its liability to recurrence. In the very unusual case of a single 
 patch of zona, or in the presence of certain bilateral zonas, the differ- 
 entiation may prove practically impossible. 
 
 The zosteriform eruptions constitute a somewhat indefinite group, 
 including rare and rather dissimilar observations. This name is 
 applied to exanthems constituted by less numerous, less definitely 
 grouped and more voluminous lesions than those of zona, occupying 
 the territory of one or several nerve trunks, but only on a limited 
 portion of this territory, accompanied by sensory disturbances, 
 muscular atrophy, vasomotor disturbances, etc. Their essential 
 characteristic is their repeated recurrence during several years. In 
 one of my patients, vesicles reappeared five or six times a year at 
 different points of the left hand, but always on the cutaneous terri- 
 tory of the median nerve, throughout a period of ten years. 
 
 Zosteriform eruptions, sometimes called chronic zona or recurrent 
 zona, are observed after traumatism of the nerves, in peripheral 
 neuritis, in diseases of the cerebrospinal axis, in syphilis, malaria, 
 etc. 
 
 Certain recurrent zonas might be classified equally well among 
 the zosteriform eruptions, but the eruption is here far from being 
 invariably unilateral. 
 
 Treatment. — The local treatment of zona must be as simple as 
 possible; avoiding moist dressings, poultices, salves, and ointments, 
 which only serve to favor infection, leading to ulceration and scar- 
 formation. It is advisable to empty the largest or confluent vesicles 
 by pricking them with a flamed needle and to apply large amounts 
 of bland, aseptic or sterilized powders, in order to favor desiccation. 
 Occlusive dressings will relieve the painful sensations. 
 
 Ulcerative or gangrenous lesions are treated in the usual way. 
 The sometimes extremely distressing pains of zona require special 
 treatment. Analgesic agents, aconite, gelsemium, antipyrin, 
 pyramidon, exalgin, aspirin, are sometimes sufficient. Morphin 
 injections must be avoided, if possible, on account of the danger of 
 the morphin habit. Injections of a cocain solution, or sterilized 
 air, along the course of the affected nerve, have been useful in a few 
 cases. Radiotherapy and galvanic electricity are valuable measures 
 in cases otherwise regarded as desperate. 
 
 For the treatment of ophthalmic zona, the reader is referred to 
 text-books on ophthalmology. 
 
CHAPTER IX. 
 PUSTULES AND PUSTULAR DERMATOSES. 
 
 The eruptive lesion known as a pustule is an epidermal elevation 
 containing a purulent fluid. The cavity containing the pus may be 
 situated in the epidermis, in the cutis, or in a follicle. A distinction 
 is accordingly made between: 
 
 1. Epidermic pustules which may be superficial when formed 
 under the horny layer (example: impetigo); or deep, when they 
 involve the basal layer of the mucous body and therefore leave a 
 scar behind them (example: variola, ecthyma); (2) Dermic pustules, 
 which are rare (example: miliary abscesses of the newborn; pustules 
 of tuberculosis verrucosa); (3) Follicular pustules, which on the 
 contrary are extremely common. The two last-named varieties will 
 be discussed in other chapters. 
 
 It would be correct and logical to reserve the name pustules for 
 primary pustules, namely, those in which the lesion is suppurative 
 from the start. In case of secondary suppuration of other eruptive 
 lesions, terms should be employed like suppurative vesicles, purulent 
 bullae, or suppurative papules, according to the condition present; 
 but as this distinction is not always practicable; the words vesico- 
 pustules, papuh-pustules, and tubercuh-pustules, are in common use 
 to obviate this difficulty. 
 
 Collections of pus in the hypoderm are not pustules, but abscisses 
 or gummas. 
 
 I' ust ales are of rounded, rarely oval configuration, more or less 
 prominent, hemispherical or flattened, tense or flaccid, of a yellowish 
 white or grayish color and surrounded by an inflammatory areola. 
 
 Their dimensions are extremely variable, they may be punctiform, 
 lenticular, or nummular; often they are small at first and undergo 
 a centrifugal enlargement. 
 
 It is usually easy to ascertain their more or less dee]) seat by means 
 of direct examinations; if necessary — and it is advisable to do so — 
 they must be punctured with a needle, in order to empty the con- 
 tents, determine the thickness and constitution of the roof, the 
 characteristics of the floor of the pustules, etc. 
 
 The contents may be a more or less turbid and yellowish fluid, 
 or consist of the creamy thickened substance known in former times 
 as "laudable pus." Examined under the microscope, it contains 
 chiefly polynuclears and plasma, 
 
PUSTULES AND PUSTULAR DERMATOSES 161 
 
 The pustules do not persist a long time, they terminate by acci- 
 dental or spontaneous rupture, or by desiccatioa. In both cases, 
 they are followed by a yellow, brown or black crust, more or less 
 thickened and irregular, covering an erosion, excoriation or ulcera- 
 tion. 
 
 The crusts — concerning which a few words are here in order 
 from a general point of view — are concretions resulting from the 
 desiccation of serous fluid, pus, or blood. Their thickness, regularity, 
 more or less hard, greasy or friable consistence, their color ranging 
 from light yellow to deep black and their adherence vary in extremely 
 wide limits and are suggestive of their origin. 
 
 Crusts form on wounds, erosions, traumatic or pathological excoria- 
 tions of all kinds, on ulcerations and on old vesicles or pustules. In 
 case of vesicles or pustules, the epidermis regenerates itself under- 
 neath the lesion, extending from its periphery toward its center, 
 eliminating it in the form of a crust; this mechanism is designated 
 as eviction. 
 
 Crusts are absent from tissue surfaces kept moist by mutual 
 contact or by dressings. 
 
 An essential difference exists between crusts made up of scales 
 which are disintegrating epidermal layers; and hyperkeratoses, in 
 which coherent horny collections are formed. 
 
 A concretion is sometimes formed by epidermal layers alternating 
 with layers of dried serum or pus ; these scaly crusts have a leaf-like 
 structure and oily consistence; they are observed in a variety of 
 conditions, notably in the eczematides. 
 
 Pustular Dermatoses. — The dermatoses in which primary or 
 secondary pustules occur are extremely numerous. 
 
 1. In the first place the pyodermatitides are characterized by 
 pustules from the start, originating on healthy skin and resulting 
 from a cutaneous infection by pus cocci. Only the impetigos and 
 ecthyma will be discussed at this time, leaving the description of 
 the follicular pyodermatitides to the chapter on the Folliculoses. 
 
 2. Several chronic infectious dermatoses are likewise pustular from 
 the start, the pathogenic agent being capable of causing suppuration 
 by itself alone (syphilis, tuberculosis, glanders, mycoses, etc.). 
 
 3. Some eruptive fevers are pustular at a certain stage of their 
 course; this is true for variola, vaccinia and sometimes varicella. 
 Cutaneous diphtheria may exceptionally assume the complete 
 appearance of impetigo vulgaris. These diseases need only be men- 
 tioned in this connection. 
 
 4. Some artificial dermatitides are, or may be, pustular from the 
 start. Mercurial agents, fumes of tar and resinous plasters some- 
 times give rise to erythemas with small scattered miliary pustules; 
 thapsia, tartrate of antimony, croton oil, etc., produce lenticular 
 
 11 
 
162 PUSTULES AND PUSTULAR DERMATOSES 
 
 pustules; oil of cade and analogous products sometimes give rise to 
 papulo-pustules. Certain toxidermas of internal origin are likewise 
 pustular (iodides, bromides). The question arises if these chemical 
 substances are pyogenic in themselves, or if, as seems probable, 
 their action is limited to favoring the penetration and activity 
 of the pyococci. The point has not yet been settled. A special 
 chapter (XXIII) will be devoted to these artificial dermatitides. 
 
 5. There still remain the secondarily and accidentally pustular 
 dermatoses. When suppuration supervenes in the eczematous or 
 vesicular dermatoses, this is evidently due to secondary infection 
 by pyococci; secondary infection, however, has not been proved 
 to be necessary in the bullous dermatoses, such as pemphigus and 
 Duhring's disease, which includes a pustular variety. 
 
 The secondary suppurations will be referred to in connection 
 with each of the dermatoses in which they are met, so that this 
 chapter deals only with the primary pyodermatitides and a few chronic 
 infections. 
 
 IMPETIGO. 
 
 The name impetigo belongs to an affection characterized by 
 inoculable and auto-inoculable purulent bulla?, appearing rapidly 
 on the healthy skin, drying in crusts which are often yellowish and 
 meliceric, the underlying epidermis being simply eroded and healing 
 in a short time without leaving scars. 
 
 Instead of developing on healthy skin, the suppuration and crusts 
 which result from the drying of the pus may appear on a wound or 
 on a pathological lesion, for instance eczema. These lesions are then 
 said to be secondarily impetiginous, or better, impetiginized. 
 
 The idea of a microbic external pyococcic origin of impetigo and 
 impetiginization dates back nearly to the first days of the discovery 
 of bacteria. As regards the responsible bacterial species, investi- 
 gators are divided into two schools, some regarding streptococci 
 and others staphylococci as the pathogenic agents. An important 
 advance was made when Sabouraud established the fact that the 
 different clinical forms of impetigo are referable to different organ- 
 isms. 
 
 There exist an impetigo streptogenes, an impetigo staphylogenes, 
 and an impetigo vulgaris, in which the two microbic species are 
 associated. 
 
 1 . Streptococcic Impetigo or Impetigo of Tilbury Fox. — The primary 
 eruptive lesion is a flaccid seropurulent blister, extending peripherally. 
 
 The blister from a hemp-seed to half a hazel-nut in size, appears 
 in a few hours on a faintly pinkish base. Its fluid may be serous, 
 stringy and at first hardly turbid, but it soon becomes cloudy and 
 is transformed into sero-pus. The roof of the blister is a thin 
 
IMPETIGO 
 
 1G3 
 
 opaline membrane, tense when the fluid is abundant, wrinkled and 
 fluctuating in the opposite case. 
 
 In consequence of evaporation, or surface extension, the bulla 
 becomes flaccid if it has not been so to begin with. It may rupture, 
 allowing its fluid to escape; or it may dry in a crust in its center, 
 while it enlarges peripherally, or more particularly on one side, 
 through detachment of the horny epidermis. At this stage the bulla 
 is always surrounded by a congestive areola. Extensive or serpigin- 
 ous bullse of this kind are met with measuring several centimeters 
 in diameter. 
 
 Finally, the lesion shrivels up to a yellowish or brownish crust 
 covering a red erosion; it lasts from four to eight days, then becomes 
 detached, leaving behind it a pinkish or purplish macule, which 
 persists a fairly long time. 
 
 Fig. 45. — Coexistence of impetigo of Tilbury Fox on the wrist, and impetigo of 
 Bockhardt at the root of the thumb, in a case of 
 
 The eruption is composed of a single bulla, or of more or less 
 numerous bulla?, resulting from simultaneous or successive infections, 
 or especially from spontaneous auto-inoculations. The bullse are 
 often in different stages of development. 
 
 Their seats of election are the face, especially around the mouth, 
 the nose and ears, sometimes in the beard or on the scalp; further- 
 more, on the extremities, affecting the hands and fingers, or the feet, 
 where they originate from excoriations caused by the shoes, etc. 
 
 The condition known as whitlow or subepidermic panaris, ["run- 
 around"] is nothing more nor less than a bulla of streptococcic 
 impetigo, derived from a fissure or a hang-nail, and having a ten- 
 dency to extend around the nail. 
 
 Other tegumentary regions are more rarely affected, except in 
 
1G4 
 
 PUSTULES AND PUSTULAR DERMATOSES 
 
 ease of gross neglect, traumatism, or scratching. In scabies, for 
 example, complication with the impetigo of T. Fox is common, 
 although less frequent than staphylococcic complications. 
 
 In the impetigo of T. Fox the glands belonging to the affected 
 
 regions are usually swollen and tender, especially when the eruption 
 is accompanied by lymphangitis; the absence of protective dressings, 
 fatigue, overwork and general debility, favor this complication. 
 These cases are associated with pain, fever, digestive disturbances, 
 prostration; the local infection may also lead to a grave but for- 
 tunately rare general disease, a streptococcic septicemia. 
 
 In contradistinction to other forms of impetigo, the impetigo of 
 T. Fox shows no predilection for a given age or sex. 
 
 A K4HMANSKI 
 
 Fig. 4fi. — Histology of impetigo of Tilbury Fox. Border of a very recent bulla 
 of the ear. The cavity is the result of splitting of the epidermis at the level of 
 the granular layer. The bulla which is subcorneal, contains a coagulated fibrino- 
 albuminous fluid, detached epithelial cells, and a small number of pus cells. The rete 
 which is not deformed and the edematous papillary body are seen to contain a few 
 wandering cells which are beginning to make their appearance. X 90. 
 
 The affection lasts from three to eight days under suitable treat- 
 ment and may persist for weeks or months under the opposite 
 conditions, or when circumstances are present favoring auto- 
 inoculations. 
 
 The 'pathological lesion consists of a bullous elevation of the horny 
 layers by a fluid composed of blood-plasm and leukocytes in vari- 
 able proportion. The mucous body and the papillary body are 
 infiltrated with more or less numerous wandering cells (Fig. 4(i). 
 
 The demonstration of the streptococcus, the primary pathogenic 
 agent, is not easy in sections; it is made by cultures in ascites-broth 
 in pipettes, according to Sabouraud's method, or by making numer- 
 ous streak-cultures on agar slants with a single platinum wire 
 
IMPETIGO 
 
 165 
 
 carrying a small amount of material, as recommended by Lewan- 
 dowsky. 
 
 2. Impetigo Vulgaris. — This is the most frequent form of impetigo 
 and is chiefly observed in children of all ages, especially from two to 
 seven years, or in adults with a delicate skin. It is highly contagious 
 and of polymicrobic origin. 
 
 It was formerly considered as the typical impetigo whose chief 
 characteristic was said to be the thick, extensive, coarse, yellow 
 crusts, which were described as meliceric on account of their resemb- 
 ling dried honey. The popular term of milk crusts is applied to 
 this impetigo as well as to impetiginized infantile eczemas and 
 seborrheal crusts, etc. 
 
 Fig. 47. — Impetigo vulgaris of the face in a child aged two years. 
 
 A crust can never be characteristic of a dermatosis as it is always 
 merely a secondary lesion. On closely following a case of impetigo 
 vulgaris, the initial lesion will usually be found to be a bulla of T. 
 Fox impetigo; this rapidly becomes purulent, dries to a crust at its 
 center while it extends at its periphery and in this way gives rise to 
 circinate crusted lesions. At the circumference appear either similar 
 lesions, or staphylococcic pustules, such as will be described further 
 on. The glands are usually enlarged. 
 
100 
 
 PT'STl'LES AM) PUSTULAR DER MATOSES 
 
 The eruption often lakes its origin near the nostrils, following 
 coryza; near the mouth, following fissures of the lips or "perleche" 
 (Fig. 17 i, near the eyelids in the case of conjunctivitis; on the 
 cars, in case of suppurative otitis; in the occipital region of the 
 scalp in children and women having head lice; on the beard; 
 where it is inoculated by means of the razor (Fig. 48). [In my 
 experience impetigo in children is almost invariably associated with 
 pediculosis capitis.] 
 
 
 
 
 4 
 
 K 
 
 V 
 
 Fig. IS. — Impetigo vulgaris, derived from inoculation with a razor. 
 
 Impetigo larvalis is the term applied to an eruption which covers 
 the fa.ee like a mask; impetigo granulata affects the seal]) or the 
 beard, giving rise to crusts whose fragments adhere to the hairs. 
 Other varieties have been described as impetigo sparsa, figurata, 
 etc. 
 
 It is not nearly so important to fit the exact descriptive term to the 
 objective appearance as to determine if the impetigo is primary or 
 secondary in character. As a matter of fact, it may point the way to 
 an infection of the mucous membranes or body orifices as stated 
 above, or complicate an eczema,, a hum, or some traumatic der- 
 matitis, scabies, lupus ( Fig. 169), syphilides, etc. These impetiginized 
 
IMPETIGO 167 
 
 eruptions are sometimes not clearly recognized unti 1 after several 
 days of treatment. 
 
 The microbes of impetigo vulgaris may become implanted and 
 vegetate wherever they find a point of entrance. 
 
 The term impetigo contagiosa has no special significance and 
 applies to cases where genuine epidemics are observed in families 
 or schools. 
 
 Impetigo has a marked tendency to recurrences which are ex- 
 plained by the persistence of virulent pyococci in the lesions, called 
 by Sabouraud the chronic remains of impetigo, such as redness and 
 crust-formation behind the ears, around the nostrils, perleche, 
 blepharitis and styes, and even pityriasis simplex (dry seborrhea). 
 These chronic infections and the adenopathies dependent upon 
 them enter into the clinical picture of scrofula. 
 
 Impetigo of the Mucous Membranes. — When astride the free 
 border of the lips, impetigo is crusted in its cutaneous portion and 
 diphtheroid in its mucous portion. Sevestre and Gaston have 
 described an impetiginous stomatitis, the characteristics of which 
 are as follows: Diphtheroid spots of a yellowish white color; 
 imbedded and incorporated in the epithelium, scattered over the 
 mucosa of the lips, the cheeks, sometimes on the tongue and palate, 
 never on the isthmus of the pharynx or in the throat; usually, 
 ulceration of the alveolar margin; a low degree of contagiousness; 
 ordinarily associated with impetigo of the face. Failure to recognize 
 this affection may result in the most annoying errors in diagnosis. 
 
 Certain coryzas, pyococcal blepharoconjunctivitis, even phlyc- 
 tenular conjunctivitis, may, strictly speaking, be interpreted as 
 impetigo of mucous membranes. 
 
 3. Staphylococcic Impetigo, or Impetigo of Bockhardt. — This is char- 
 acterized by a primary pustule, containing yellowish creamy pus, 
 often centered by a hair and surrounded by a congestive areola. 
 The lesion has the size of a pin-head to that of a large lentil; the 
 pus collects under the horny laver, elevating and distending it 
 (Fig. 49). _ 
 
 A perifollicular seat is common but not constant and Bockhardt's 
 impetigo has so many points of contact with impetigo vulgaris that 
 it must be grouped with the latter rather than with the folliculitis. 
 The pustules are usually multiple, often very numerous and are 
 grouped in one or more regions whence they may spread. The 
 eruption has no preference for special parts of the body, but develops 
 at any point where the horny layers have ceased to oppose an efficient 
 barrier against the penetration of the pyococci. This occurs in 
 cases of traumatism, scabies, chemical dermatitis, or epidermal 
 maceration through the application of a simple poultice or plaster. 
 Preexisting suppurations, dirt, pruritus and neglect, constitute 
 
168 PUSTULES AND PUSTULAR DERMATOSES 
 
 conditions favorable to its development. A youthful age, lymphat- 
 ism, overexertion, etc., seem to act as predisposing factors. 
 
 The pustules of staphylococcic impetigo appear in a few hours, 
 being more resistant than those of the preceding forms; they rupture 
 late or accidentally. The pus is then thickened into yellow crusts. 
 Unopened pustules shrivel up first in the center and are cast off" by 
 eviction. 
 
 Bockhardt's impetigo is accordinglv merely one of the elementary 
 forms of cutaneous staphylococcia, the most superficial and most 
 benign type of the disease. There exist intermediary forms between 
 the impetigo of Bockhardt and the more or less deep folliculitides 
 (Plate II). Combinations with other forms of staphylococcia 
 frequently occur. 
 
 
 • i ... 
 
 Fig. 49. — Histology of the pustule of Bockhardt's impetigo. The cavity of the 
 pustule is situated within the rete; its roof is formed by the horny layer, doubled in 
 places by the granular layer; its floor is represented by the lower strata of the rete, 
 which are seen to be crowded and flattened. The oblique section of two downy 
 hairs may be seen floating in the purulent contents of the pustule. X 60. 
 
 A bullous form of impetigo, generally known under the name of 
 epidemic pemphigus of the newborn will be discussed further on p. 178. 
 
 The affection described under the name of infantile vacciniform 
 dermatitis by Hallopeau, vacciniform herpes, by Founder, is probably 
 merely a variety of impetigo. It appears in the form of erythematous 
 spots, the epidermis of which is rapidly raised by a turbid fluid, 
 with central umbilication. It is observed in neglected infants, 
 especially around the ano-genital region. The eruption may simu- 
 late varicella. 
 
 Treatment. Every practitioner should know how to treat impetigo. 
 Whether it be primary or secondary, the treatment is the same, but 
 in the latter case, after the complication has been removed, the 
 original dermatosis will require attention. 
 
 In the first place, the treatment must be local. A fundamental 
 rule is to get rid at once of all crusts or active inflammation that 
 
ECTHYMA 169 
 
 may be present. This will be accomplished in a day or two by means 
 of moist softening or slightly antiseptic dressings, sprays or starchy 
 poultices, to be applied cold. At each dressing, at least three times 
 in twenty-four hours, antiseptic or astringent lotions must be applied ; 
 the solution which for some time has achieved, or rather resumed 
 general and well deserved favor is Alibour water, the formula of 
 which dates back to the reign of Henri IV. As soon as the surfaces 
 are cleansed, pastes or salves made with boric acid, camphor, white 
 precipitate and especially yellow precipitate are indicated. A mer- 
 curial plaster is serviceable for the isolation of scattered lesions of 
 impetigo. Camphorated lotions or ichthyol pastes help to prevent 
 recurrences. 
 
 Internal treatment, contrary to a commonly held view, is by no 
 means indispensable, and must never be considered as sufficient by 
 itself alone. It may be necessary sometimes to prescribe cod-liver 
 oil, iron iodide, arsenic, or the ferments and yeasts. Dietetic 
 measures, residence by the seaside, or mineral springs, influence 
 only the general condition. 
 
 ECTHYMA. 
 
 The meaning of the term ecthyma has undergone some slight 
 changes, according to different authors and at different times, so 
 that it is somewhat difficult to separate ecthyma from the impetigos, 
 from rupia of the older writers and from ulcers of the skin. 
 
 Ecthyma actually represents a pustulo-idcerative pyodermatitis; 
 namely, a microbic dermatitis of external origin (XXVI) like impetigo, 
 beginning like the latter with a pustule, but differing from it by the 
 greater dimensions of its lesions and especially by their ulcerative 
 character. The ulceration is frequently covered by a crust, which 
 may be rupioid. Ecthyma always leaves a scar behind it. Like 
 all other pyodermatitides, it is inoculable and auto-inoculable. Its 
 special clinical characteristics are referable to a peculiar virulence 
 of its pathogenic agents, or to a deeper inoculation of these agents, 
 favored by some tissue lesion or preliminary affection, or finally 
 to the soil on which it develops. 
 
 When the mode of formation of an ecthyma lesion can be watched, 
 it is seen to begin with a pustule, usually flattened and with turbed 
 contents, like the impetigo of T. Fox, more rarely tense and con- 
 taining a creamy pus, like the impetigo of Bockhardt. 
 
 This pustule, having very rapidly reached nummular dimensions, 
 shrivels up into a more or less thickened, yellowish or brown, 
 adherent crust, which is flattened or protuberant, sometimes 
 ostreaceous, surrounded at first by a bullous collar and always by 
 a congestive halo. When this crust falls off or is removed by means 
 
170 PUSTULES AND PUSTULAR DERMATOSES 
 
 of the dressings, it is seen to cover a rounded or oval ulceration, 
 more or less deeply encroaching upon the derma. Its borders are 
 regular and clean-cut; the floor is red or pultaceous, sloping toward 
 the center in the stage of advance, granulating in the stage of repair; 
 the secretion consists of viscid or clotted brownish and blood-tinged 
 pus; the base is not indurated, but sometimes diffusely edematous. 
 
 After lasting two or three weeks in favorable cases, but much 
 longer under bad conditions, the ulceration heals through granula- 
 tion and cicatrization; the scars are often pigmented at their border. 
 
 Glandular enlargement, lymphangitis, phlebitis, abscesses, are rare 
 complications. 
 
 The lesions are usually multiple, rarely very numerous and, as a 
 rule, of different ages, having originated from successive auto- 
 inoculations. 
 
 Fig. 50. — Eethyma oi the leg. The lesions have been deprived of their crusts and 
 cleansed by means of moist dressings. 
 
 Ecthyma has its .scat of election on the lower limbs (Fig. 50); the 
 buttocks and the back are less frequently affected, the part played 
 by congestion and circulatory stasis is therefore very evident. 
 
 Ecthyma is usually observed only during the first half of life; it 
 affects overstrained, weakened, scrofulous, diabetic, varicose, or 
 alcoholic subjects; not uncommonly, it is induced by scratching 
 due to uncleanliness, or by scabies and lice. Ecthyma has figured 
 to a great extent among the soldiers in the trenches. 
 
 There are no valid reasons for distinguishing a cachectic ecthyma, 
 ;i scrofulous ecthyma, etc., nor is it correct to describe as scabies- 
 ecthyma all the pyodermatitides complicating the itch. The anti- 
 quated terms of syphilitic ecthyma and syphilitic rwpia, to designate 
 ulcerative syphilides, are altogether objectionable. 
 
ECTHYMA 
 
 171 
 
 In the presence of unfavorable nutritional conditions and local 
 circulatory disturbances, an ecthyma pustule may become the 
 starting-point of a leg-ulcer. 
 
 The pathological anatomy of ecthyma, in the ulcerative stage, 
 shows a deep and remarkably distinct ulcer, bordered by a thin 
 layer of leukocyte infiltration; apparently resulting from molecular 
 disintegration and not from sloughing. The pus contains tissue- 
 debris, elastic fibers, altered red corpuscles, and various cocci. 
 
 Ecthyma is ascribed by authors either to the streptococcus or to 
 a microbic association. Vidal's statement that experimental inocu- 
 lation of ecthyma-pus will produce this dermatosis, but no other pyo- 
 dermatitides, is not strictly correct; however, the ecthyma-eruption 
 
 Fig. 51. — Erythema terebrans of the back in a child a,ged two and a half years. 
 
 is not infrequently pure and is not associated with other pyococcic 
 manifestations. According to recent investigations of Lewandowsky 
 ecthyma seems to be a simple streptococcia, closely related to the 
 impetigo of T. Fox and with a slight tendency to become secondarily 
 infected. 
 
 The name ecthyma terebrans is applied to a pustulo-ulcerative 
 eruption in children, rare and rather obstinate, occupying the 
 buttocks, thighs, and back progressing by contiguity, in the form 
 of lenticular, sometimes vacciniform or even gangrenous pustules 
 (gangrenous varicella of English and American writers). These 
 pustules become confluent and give rise to enormous polycyclic 
 
172 PUSTULES AND PUSTULAR DERMATOSES 
 
 ulcerations, with festooned margins, a grayish floor and dusky cir- 
 cumference, leaving honey-combed cicatrices (Fig. 51). This grave 
 eruption lias been observed especially in weakly newborn infants 
 suffering from diarrhea (Neumann's ecthyma of cachectics) ; excep- 
 tionally also in older children and even in adults. According to 
 Bosellini and others, the affection is due to the bacillus pyocyaneus. 
 
 The treatment of any ecthyma of the lower limbs requires rest, in 
 bed, moist applications to loosen the crusts, followed by lotions of 
 Alibour water or peroxide water; the ulcers are then dressed with a 
 salve or paste of yellow oxide, or an absorbent or antiseptic powder 
 may be used, such as dermatol, aristol, etc. Touching with a silver 
 nitrate solution may prove useful. During the stage of repair, the 
 ulcerations are advantageously covered with red oxide ointment or 
 balsam of Peru. 
 
 General treatment is not usually necessary; regulation of the 
 patient's hygiene will suffice. 
 
 PUSTULES OF THE INFECTIOUS CHRONIC DERMATOSES. 
 
 Syphilis, tuberculosis, glanders and certain mycoses and tropical 
 diseases may give rise to pustular .syndromes. 
 
 Syphilis. — There exist syphilides which are only apparently 
 pustular; no drop of pus can be obtained by puncturing them with 
 a needle. Such syphilides are known as papulo-crusted or impeti- 
 ginous syphilides. They are generally mixed in with a crop of 
 lenticular papules, of which they are merely a variety; or they may 
 predominate in a given eruption. 
 
 The more or less profuse eruption is irregularly scattered over the 
 trunk, limbs, face and scalp; it consists of round lenticular crusts, 
 brownish-yellow, swollen, slightly adherent, sometimes exuberant, 
 ostreaceous or rupioid (see Fig. 94), which cover a papule with a 
 smooth moist surface, instead of an ulceration, as one might be led 
 to believe. 
 
 Precocious malignant syphilides of the ecthymatoustype begin, before 
 undergoing ulceration, with a large papule the epidermis of which is 
 raised by pus; this hardens into a crust; under this crust and at its 
 periphery the ulceration develops and progresses. 
 
 Tuberculo-crusted syphilides, which are apt to be circinate, are only 
 transitorily pustular; they belong rather to the tuberculo-ulcerative 
 eruptions. 
 
 Tuberculosis. — Tuberculous ulcers begin as very small papulo- 
 pustules which open and coalesce. In tuberculosis verrucosa, deep 
 pustules are almost regularly seen, the contents of which can be 
 squeezed out by compressing the vegetating patch between the 
 fingers. 
 
PUSTULES OF INFECTIOUS CHRONIC DERMATOSES 173 
 
 There exists a form of lupus exedens which is entitled to the name 
 of pustular lupus. 
 
 It is especially important to keep in mind the very frequent 
 occurrence of impetiginous changes in eroded lesions of lupus; 
 fungoid tubercles, open scrofulous gummas, or atypical tuber- 
 culous ulcers becoming covered with yellow or brownish crusts. 
 A diagnosis of impetigo or ecthyma must be carefully excluded in 
 such cases. In the absence of information regarding the develop- 
 ment, it suffices to detach or otherwise remove the crusts, to bring 
 into view the grave underlying lesions. 
 
 Papulo-necrotic tuberculides are genuine pustules at a certain stage 
 of their development. They are generally recognized by their very 
 peculiar course and sometimes by their topographical distribution. 
 
 Glanders. — One of the clinical features of acute glanders consists 
 in a pustular eruption resembling that of smallpox. The round, 
 non-umbilicated pustules form rapidly, occupying especially the 
 face, the mucous membranes and the limbs; they rupture later on, 
 leaving extensive ulcerations. The general symptoms suggest the 
 diagnosis which must be confirmed by bacteriological methods. 
 
 The mycoses (sporotrichosis, etc.), Leishmaniasis (Biskra boil or 
 button) and verruga Peruviana may give rise to pustules at their 
 onset, or in the course of the disease (XXIX). 
 
CHAPTER X. 
 BULLAE AND BULLOUS DERMATOSES. 
 
 BuiJLffi or phlyctenes (blebs) are eircumscribed elevations of the 
 epidermis containing an ordinarily clear and serous, sometimes 
 turbid or hemorrhagic fluid; when the fluid consists of pus, the lesion 
 becomes a purulent bulla. 
 
 Hulhe differ from vesicles by their generally larger size as well as 
 by their structure and mode of formation. Their shape is round or 
 oval and their size varies from that of a pin-head to that of a hen's 
 egg or larger; their surface is tense or flaccid. They terminate 
 through rupture, suppuration, or simple desiccation; in all these 
 cases, they are followed by a crust of variable color and thickness 
 according to the character of the exudate, covering a more or less 
 dee]) erosion. The crust becomes detached in five to fifteen days, 
 leaving almost invariably a temporary red or brownish macule in 
 its place. 
 
 Blebs or bullae do not result from a progressive process, like vesicles, 
 but from a genuine splitting of the epidermis. Their cavity is there- 
 fore unilocular from the start; when the fluid contents have been 
 emptied, through pricking or tearing the bulla, it collapses entirely. 
 
 Two processes are concerned separately or jointly in the formation 
 of bulla?. Most frequently they follow a local dermic edema, the 
 edematous fluid under high pressure filtering through the Mal- 
 pighian layer, until it is arrested by the horny layer which it raises 
 by accumulating below it. This results in the production of a 
 superficial or .subcorneal bulla (Figs. 46 and 58). 
 
 In other cases, the still more sudden rush of fluid detaches the 
 epithelium as a whole, giving rise to a deep or subepithelial bulla 
 (Fig. 56.) 
 
 In ease of the second mode of bleb-formation, the mutual cohesion 
 of the cells of the mucous body is pathologically diminished; the 
 intercellular Glaments have lost their resistance; they separate under 
 the influence of the slightest excess of pressure of the intercellular 
 plasma. This abnormal condition is designated as acantholysis, 
 after Auspitz, and the resulting bullae are known as arantholi/tic 
 bulla: 
 
 Bullous Dermatoses. -The group of bullous dermatoses is very 
 extensive and very complex. The older writers interpreted all 
 
ACCIDENTALLY BULLOUS DERMATOSES 175 
 
 bullous eruptions as pemphigus, a circumstance which resulted 
 in extraordinary and persistent confusion. This designation is now 
 reserved for a small minority of these cases. The following eruptions 
 do not belong under the heading of pemphigus: 
 
 Traumatic bulla', or blisters, produced by strong pressure [or 
 friction] ; and those which result from burns, or from the action of 
 caustics and vesicants. These are artificial external dermatitides 
 of bullous form and will be discussed further on (XXIII). 
 
 Bullae, occurring as epiphenomena in the course of definite nervous 
 or infectious diseases, such as syringomyelia, leprosy, purulent 
 infection, etc. 
 
 Accidentally bullous dermatoses, such as erysipelas, eczema, 
 dysidrosis, ichthyosiform hyperkeratosis; mention must be made 
 of bullous urticaria, bullous polymorphous erythema or hydroa, 
 bullous syphilides and bullous toxicodermas of internal origin. 
 
 External microbic bullous eruptions, which according to Unna are 
 all entitled to the name of impetigo. Although it remains doubtful 
 if certain pathological varieties should be grouped under this heading 
 rather than with acute pemphigus, this seems to be justifiable as 
 regards the so-called epidemic pemphigus of the newborn and of 
 adults, which is really a bullous impetigo. 
 
 Eliminating these forms there are left some essentially bullous 
 affections, of undetermined but decidedly variable type, which are 
 designated as pemphigus, and include: (1) Pemphigus acutus 
 febrilis gravis. (2) Recurrent polymorphous pemphigus, or Duhring's 
 dermatitis; (3) Pemphigus chronicus; (4) Pemphigus foliaceous; 
 (5) Pemphigus vegetans; (6) Pemphigus congenitalis. So-called 
 pemphigus hystericus will later be considered in a few lines. 
 
 Accidentally Bullous Dermatoses. — Some of these require special 
 mention on account of the difficulties of diagnosis and interpreta- 
 tion which they may occasion. 
 
 Bullous Urticaria. — This is a rare variety of urticaria in which all 
 or some of the lesions become crowned with a bullous prominence, 
 followed by a crust. The eruption may be chronic or recurrent. 
 In view of the pruritus and the erythematous base of the bullae, this 
 affection may be confused with Duhring's dermatitis, from which 
 it is distinguished by its irregular distribution and the absence of 
 true polymorphism, each bulla originating on .in urticarial wheal. 
 Sometimes, it is possible to demonstrate a tendency to urticaria in 
 the patients. 
 
 Bullous Polymorphous Erythema or Hydroa. — In certain cases of 
 polymorphous erythema, localize 1 as usual on the back of the hands, 
 on the wrists, elbows, knees, on the face and especially on the 
 forehead, etc. (Fig. 52), some lesions or most of them may become 
 the seat of vesicles or of tense bullae which when pricked with a 
 
176 
 
 BULLM AND BULLOUS DERMATOSES 
 
 pin void a lemon-yellow or reddish-fluid. The bullae occupy the 
 entire surface of the papular elevations or only their center; some- 
 times they are situated at the periphery. 
 
 Fig. 52.— Erythema bullosum; first attack, in a gir] aged eleven years. (The buccal 
 mucosa were affected a1 several points. 
 
 I ,,,. 53 Erythema bullosum of the variety hydroa vesiculareof Bazin, or herpes iris 
 of Bateman. 
 
 The name of Bazin's hydroa, or herpes iris of Bateman, is applied 
 to a variety in which the lesions, consisting of a small bulla or central 
 crust, surrounded by a bright red or purplish disk, a vesiculo- 
 bullous circlet and narrow erythematous border, present a striking 
 cockade-like arrangement (Fig. 53). 
 
BULLOUS TOXICODERMAS 111 
 
 The eruption often affects also the lips, the mouth, the tongue, 
 the pharynx and the other mucous membranes. 
 
 Hydroa biiccale, characterized by bullous elevations which are 
 rapidly replaced by very painful nummular deep red or diphtheroid 
 erosions, simulates and is sometimes mistaken for mucous patches. 
 In exceptional cases it may be accompanied by fever and infectious 
 symptoms, with severe visceral complications. 
 
 Polymorphous bullous erythema usually lasts from two to five 
 weeks; it may be prolonged beyond that time by successive erup- 
 tions, or it may recur at variable intervals in a number of attacks. 
 This tendency to relapse and the unusual severity of the sensations 
 of itching and heat, in some cases result in so close a resemblance 
 to Duhring's disease as to render the diagnosis necessarily doubtful. 
 
 Bullous Syphilides. — The eruption known under the name of 
 syphilitic pemphigus is met with on the palmar and plantar regions 
 of newborn children with congenital syphilis. It consists of papular 
 lesions of a purplish or coppery hue, discrete or confluent, the epi- 
 dermis of which is raised by a turbid or blood-stained fluid; the 
 dimensions of the bullae vary from those of a hempseed to those of a 
 large bean, but confluence in extensive patches may occur. 
 
 In two or three days, these bullae dry into crusts, covering an 
 ulceration. Their fluid contents and especially the fluid obtained 
 by scraping their floor, contain enormous numbers of spirochetes. 
 It is exceptional for the eruption to become generalized under the 
 same form; but a few aberrant bullae, or syphilides of another type, 
 may be found in other portions of the body. 
 
 This eruption, the only syphilide assuming a bullous form, appears 
 almost exclusively at the time of birth, a few days before or after. 
 It is pathognomonic. 
 
 Bullous Toxicodermas. — Aniipyrin bulla? represent a transforma- 
 tion of the erythematous patches produced by antipyrin in some 
 individuals (Fig. 145). They originate abruptly in any region, 
 especially the genitals and the mouth, reappearing with each 
 repeated administration of the drug and leave a brown discoloration. 
 
 Iododerma bulbsum is a rare affection produced by potassium iodide 
 or its congeners; the lesions may be clear, distinctly pemphigoid bullae, 
 of rapid development, located especially on the neck or in the folds 
 (Fig. 146); or the condition may consist of very rapidly purulent 
 and extensive bullae, the center of which becomes fungoid arid 
 crusted, situated in very variable numbers on the face, the mouth, 
 the limbs or the trunk; they suggest the fungoid syphilides or more 
 particularly pemphigus vegetans. This eruption may persist during 
 several weeks, especially if the medication is continued. 
 
 Bromides, arsenic, etc., are likewise capable of causing the' 
 appearance of blisters. 
 12 
 
178 BULLJE AND BULLOUS DERMATOSES 
 
 BULLOUS IMPETIGOS. 
 
 The impetigos are pyodermatitides the eruptive lesion of which 
 is a pustule or a purulent bulla; they are all more or less contagious. 
 
 A somewhat distinct bullous type is generally described under the 
 name of epidemic pemphigus of the newborn. It is encountered in 
 nursing infants, in asylums, hospitals, or even in families— more 
 rarely in adults — in the form of an acute eruption of clear tense hemi- 
 spherical bulhe, the size of a lentil to that of a nut; from one to about 
 thirty in number. They occur in the folds of the neck, trunk and 
 limbs, rarely on the face, but are never encountered in the palmar 
 and plantar regions. 
 
 These bulla? supervene in healthy or in marasmic children, in 
 successive crops, in the form of red spots which very rapidly become 
 blisters; at the end of a few hours the bulla ruptures and the thin 
 crust falls off in a few days. Recovery is the rule; exceptionally , in 
 weakened patients, symptoms of severe general infection have been 
 noted. 
 
 3 i» 
 
 Fn;. .54. — Impetigo bullosum in a child aged sixteen months. 
 
 This affection is highly contagious. Vida] has shown that it is 
 possible to inoculate and auto-inoculate the fluid of the bulhe. It 
 contains, according to Peter, the Staphylococcus aureus, some albus 
 and a special diplococcus which is by several authors considered the 
 cause of the disease; perhaps, in addition, a streptococcus. The 
 Staphylococcus aureus is regarded as the real pathogenic agent by 
 Dohi and Jadassohn. 
 
 Bullous impetigo is sometimes observed also in older children 
 (infantile pemphigoid of Jadassohn) in combination witli various 
 pyodermatitides (Fig. 54). 
 
 Confusion must be avoided with varicella, generalized vaccinia, 
 impetigo vulgaris and the bullous syphilides. However, the features 
 
RECURRENT PEMPHIGUS OR DUHRING'S DISEASE 179 
 
 of these various eruptions are usually sufficiently distinct to guard 
 against errors in diagnosis. 
 
 The treatment consists in extreme cleanliness, absolute hygiene 
 and isolation of the patient. Locally, washing with Alibour water 
 will suffice, and dressings with a bland powder, an oil and lime 
 liniment, or yellow precipitate salve. 
 
 PEMPHIGUS ACUTUS FEBRILIS GRAVIS. 
 
 This is a systemic infectious disease, with a bullous eruption, 
 studied by Nodet (1880), George Pernet (1895-1896) and Brocq; 
 it affects almost exclusively butchers, sausage-makers, pork- 
 choppers, tanners, cooks, etc., namely persons who handle dead 
 animals. The infection usually follows upon some injury of the hand, 
 manifesting itself, abruptly by chills, prostration, vomiting or diar- 
 rhea, delirium or depression and a temperature of 40° (104°). The 
 eruption appears twenty-four to forty-eight hours later, in the form 
 of tense bullae with yellowish or hemorrhagic contents; originating 
 on red spots and almost invariably undergoing rupture. It occupies 
 the neck, the chest, the limbs or the entire body; discrete at first, it 
 soon becomes confluent and may involve the mucous membranes. 
 Death results in over three-fourths of the cases, at the end of one 
 to three weeks, under typhoid symptoms, albuminuria, various 
 congestions, etc. Recovery takes place through gradual subsidence 
 of the symptoms in three to six weeks. 
 
 The anatomical lesions of acute pemphigus and its pathogenic 
 microbe are unknown. The condition evidently represents a 
 variety of septicemia. 
 
 The indications are to combat the infection by means of quinine, 
 collargol, serum injections and intestinal irrigation, and to support 
 the organism by all possible means. Moist or oily dressings, cotton 
 wraps, and so forth serve to relieve the burning sensation which is 
 often extremely distressing. 
 
 RECURRENT PEMPHIGUS, DUHRING'S DISEASE OR 
 POLYMORPHOUS DERMATITIS (BROCQ). 
 
 A well-characterized dermatosis in typical cases was described 
 by Duhring, in 1884, under the name of dermatitis herpetiformis. 
 
 This affection, which the Vienna School confused with chronic 
 pemphigus and multiform erythema, was designated by the old 
 French writers as pemphigus with small bulla?, or pruriginous 
 pemphigus, or "arthritide bulleuse" (Bazin). English authors, 
 following Tilbury Fox and Colcott Fox, prefer the name of hydroa 
 herpetiforme. 
 
180 
 
 BULLM AND BULLOUS DERMATOSES 
 
 In the opinion of Brocq, who thoroughly investigated this ques- 
 tion the disease is entirely distinct from pemphigus; and since the 
 eruption is far from being invariably herpetiform, he extended the 
 scope proposed by Duhring and established a group of painful poly- 
 morphous dermatitides [dermatites polymorphes douloureuses] com- 
 prising numerous forms or varieties. This view is becoming more 
 and more generally adopted. 
 
 Personally, like many others, I put together under the name ot 
 Duhring's disease all the varieties of the disease, of which the 
 American author originally described only the form with small 
 vesiculaT lesions. Instead of attempting to multiply the clinical 
 types, according to the dimensions of the bullae, etc., I shall endeavor 
 to map out a general view, in the following description: 
 
 1 ig. 55. 1 termatitis 
 
 of Duhring. Anterior aspect of arm and right axilla. 
 
 Symptoms. E 
 disease: 1 Tfc 
 
 ,,■ clinical features arc characteristic of Duhring's 
 polymorphism of the eruption; 2 painful phe- 
 nomena, usually very pronounced: (3 the usual preservation of 
 
 ] general health; 1 the tendency to recurrences. [The tetrad 
 
 of symptoms which seem most characteristic are: The polymor- 
 phic. i of the lesions; their more or less marked herpetic grouping; 
 the pruritus and the tendency to recurrences. Sensations of pain 
 
RECURRENT PEMPHIGUS OR DUE RING' S DISEASE 181 
 
 are noted in the minority of the cases in my experience.] The onset 
 is marked sometimes by the eruption, sometimes by a preliminary 
 pruritus. 
 
 1. The eruption is polymorphous and presents itself under very 
 variegated aspects (Fig. 55); it often covers a large portion of the 
 limbs and the body. It is composed of erythematous patches, 
 papules, vesicles, bulla? and sometimes pustules. 
 
 The multiple spots or erythematous patches are often urticarial 
 and marginated ; in the same case, they may have nummular dimen- 
 sions or resemble large polycyclic surfaces; more rarely, simple 
 papules are met with. 
 
 A tendency to bleb-formation manifests itself early through the 
 appearance, on the surface of the patches, of sometimes uniform, 
 herpetiform, grouped or scattered vesicles, often arranged as a 
 border; or bulla? may be seen, from the size of a pea to that of a nut, 
 with clear or rapidly purulent contents. Vesicles or bullae may also 
 originate in the healthy skin in the vicinity of the patches, or they 
 may swarm out to a distance. In a general way, the figured erythe- 
 matous patches, interspersed with herpetiform vesicles or bulla? are 
 the most characteristic feature. 
 
 The most frequent initial localization is on the limbs, especially 
 on the forearms; but the eruptioa may start anywhere. It proceeds 
 by enlargement of the primary lesions and the production of new 
 lesions, appearing every two or three days in small numbers, or in 
 large crops every five to ten days. The duration of each lesion is 
 limited, however. The erythema fades; the vesicles and bulla? 
 burst through scratching and are replaced by red surfaces, raw or 
 covered with crusts; the latter fall off and leave pigmentary macules, 
 very rarely cicatrices. Lesions of different age are thus present at 
 the same time. 
 
 As a rule, the eruption is decidedly symmetrical. It affects espe- 
 cially the limbs, the buttocks, the chest, etc., but has a tendency to 
 cover the entire body; possibly the face, the scalp, the palms of the 
 hands and the soles of the feet are less frequently involved. When 
 the last-named regions become keratotic, arsenic medication may 
 possibly be responsible. 
 
 The mucous membranes, more particularly the buccal mucosa, are 
 affected in nearly one-half of the cases; the lesions here resemble 
 those of hydroa. [Involvement of the mucosa is by no means so 
 frequent in this country as in the author's experience.] 
 
 An endless number of eruptive varieties might be described; but 
 it is enough to point out that the predominant lesion may take the 
 form of erythema, or of herpetiform vesicles, these being the cases 
 which Duhring had in mind, or of bulla?, which led Kaposi and his 
 school to see in this affection merely a modified form of pemphigus 
 
182 BULLM AND BULLOUS DERMATOSES 
 
 vulgaris. American and English writers have described a pustular 
 variety, with pustules from the onset. Sometimes the bullae are 
 extensive and plainly vegetative in character. 
 
 Cases are observed in which the eruption is localized in a certain 
 region of the body; other cases in which polymorphism is absent, 
 notably in children or youthful individuals, vesicles or bullae occur- 
 ring exclusively. In still other cases, on the contrary, nothing is 
 seen but patches of marginate erythema, incessantly recurrent and 
 pruritic, with very scanty vesiculation. 
 
 2. The painful phenomena are one of the fundamental charac- 
 teristics of Duhring's disease, but cannot be considered as constant 
 and pathognomonic, as claimed by Besnier and Brocq. They con- 
 sist of sensations of itching, heat, burning or acute pain. They may 
 precede the eruption by a few days, but are especially liable to 
 accompany each crop, with exacerbations in the evening and during 
 the night. Although usually of moderate severity, the patient's 
 sufferings may reach an intolerable degree, and have even led to 
 suicide. 
 
 3. The general condition, notwithstanding the very extensive 
 cutaneous lesions, the pruritus and the insomnia remains remarkably 
 good, the patients eating and digesting well and losing no flesh. 
 In exceptional cases attacks of diarrhea or a slight rise of tempera- 
 ture have been noted. The visceral complications (pulmonary and 
 especially renal) which have been said to occur, are probably 
 referable to intercurrent diseases. 
 
 4. The course is variable. Attacks as described above last from 
 six weeks to three months, sometimes six months or a year. But 
 they are often followed by a subsidence, or even a return to normal, 
 lasting several weeks, several months or even a year or longer, 
 then a new attack supervenes, and so on at irregular intervals, up 
 to ten or fifteen times. Finally, the attacks become milder and 
 ultimately cease. The proportion of recoveries can hardly be 
 specified. 
 
 The disease is sometimes prolonged until death, which in rare 
 cases is due to pemphigus foliaceus or to cachexia: much more fre- 
 quently to an intercurrent affection. Hence, although Duhring's 
 disease must tie considered as very grave, this is rather on account of 
 its long duration, the suffering caused by it and the interference with 
 social relations which it entails than on account of a risk to life. 
 
 Its practically constant tendency to proceed not only in small 
 distinct or continuous crops, but in attacks or recurrences separated 
 by periods of subsidence, seems to me to constitute one of its most 
 characteristic features. 
 
 Cases with identical symptoms are observed, however, in which 
 the disease is restricted to a single attack, mild or severe. These 
 
RECURRENT PEMPHIGUS OR DUH RING'S DISEASE 183 
 
 may be classified under polymorphous erythema. Brocq admits a 
 group of acute non-recurrent painful polymorphous dermatitis. 
 
 Pathological Anatomy. — The erythematous plaques are composed 
 of congestion, with well-marked edema and abundant diapedesis 
 in the papillary body; eosinophile cells are present in large numbers. 
 
 The bullse form as the result of subepidermic rupture (Fig. 56), 
 sometimes subcorneal rupture. Occasionally they result from 
 enlargement of interstitial vesicles. Deep or superficial bleb- 
 formation is accordingly observed in this disease together with 
 vesiculation. 
 
 The fluid of the vesicles or bulla? contains at first a large pre- 
 ponderance of eosinophiles, in a proportion of 30 to 95 per cent. 
 The blood usually shows from 12 to 15 eosinophiles in 100 white 
 corpuscles, sometimes only 5 per cent., exceptionally up to 30 per 
 cent. There are no constant visceral or nervous lesions. 
 
 Fig. -56. — Histology of Duhring's disease. Section of one of the bullae represented 
 in Fig. 55. Note that the bulla is subepidermic; the epidermis has been raised as a 
 whole by the fluid exudate. Among the white corpuscles seen at the floor of the 
 cavity or scattered in the cutis are many eosinophile cells. X 50. 
 
 Etiology and Character. — Although a rare affection, Duhring's 
 disease is nevertheless the most common bullous disease of the 
 pemphigus group. It seems to be more widely distributed in England 
 and in America. It is observed in very young children, in youthful, 
 middle-aged or old individuals, in both sexes alike. [In American 
 dermatological practice it is seen in the ratio of one case out of five 
 hundred.] 
 
 The etiology is unknown and the cause has been sought in a neuro- 
 pathic constitution, overwork, emotional disturbances, alimentary 
 or medicinal intoxications. The disease is not at all contagious 
 nor can it be inoculated. Two principal theories are held by the 
 majority of writers: Some believe that endogenous or exogenous 
 
1S4 BULLM AND BULLOUS DERMATOSES 
 
 toxins of microbic or other origin act upon the nervous system, 
 causing the pruritus and the eruption. In the opinion of others the 
 eosinophils, which in this disease exists in the blood as well as in 
 the cutaneous lesions (as shown by the investigations of Leredde 
 and Ch.Perrin), indicates its hematogenous origin (hematoderma), 
 the bone-marrow being probably primarily affected. 
 
 Eosinophilia, the significance of which is, moreover, imperfectly 
 understood, may, however, be absent in Duhring's disease, whereas, 
 on the contrary, it sometimes [commonly] exists in other bullous 
 affections, pemphigus foliaceus, pemphigus vegetans and even 
 exceptionally in chronic pemphigus, as I have been able to demon- 
 strate. 
 
 Treatment. — All lotions and applications in common use for itching 
 affections June been tried, with variable results. Some cases may 
 derive benefit from the employment of absorbent powders, or moist 
 dressings, which, however, tend to mac-crate the epidermis; or 
 from the application of Hme-and-oil liniment or various creams; 
 while others do well under simple pastes, or even sulphur or tar 
 pastes. Large bulla? should be pierced with a flamed needle; the 
 excoriations are dressed with naphtalan, cold cream or lanolin. In 
 ease of very extensive lesions where the dressing exhausts the patient 
 too much, he may be placed between two sheets in a thick layer of 
 talcum powder (dry treatment). 
 
 (lateral Treatment- 'Die most popular internal treatment is 
 arsenic, in progressive long-continued doses, administered in hypo- 
 dermic injections, if necessary. Novarsenobenzol has been found to 
 be very efficacious in certain cases. Balzer advocates adrenalin. 
 I have sometimes obtained remarkable but very unreliable results 
 from repeated injections of physiological salt solution or isotonic 
 sea-water, or sugar solutions, hypertonic or not. It must be kept in 
 mind that hypodermic injections in large doses, and still more so 
 intravenous injections, with or without preliminary bloodletting, 
 may give rise to a well-marked febrile reaction. It is desirable to 
 further investigate this mode of medication, as well as serotherapy 
 with organic sera in its different forms (autoserotherapy, etc.). [On 
 the subject of autoserotherapy the views of American authors are 
 greatly divergent; a few speak enthusiastically of its value, others 
 find it of no use.] 
 
 In all cases a very strict diet must be prescribed, free from 
 stimulants, preferably a milk diet, and all organic functions must be 
 carefully supervised. 
 
 Rare Dermatoses Related to Duhring's Disease. — Under this 
 heading I have grouped a number of pathological forms which have 
 received special names, but are perhaps merely varieties of the dis- 
 ease described above. This remark is certainly true of herpes 
 
RECURRENT PEMPHIGUS OR DUH RING'S DISEASE 185 
 
 gestationis of Milton and Duncan Bulkier. This condition is really 
 a Duhring's disease, with the special characteristic of developing in 
 the course of pregnancy, in the fifth to sixth month, or sometimes 
 after delivery. The attack lasts a few weeks to several months. 
 Recurrence is the rule with each succeeding pregnancy, each attack 
 occurring earlier in the course of the gestation and lasting longer. 
 
 Hydroa puerporum of Unna is in all probability likewise a form 
 of Duhring's disease, appearing in young children in the form of 
 acute polymorphous attacks, recurring especially in the summer 
 and disappearing around the age of puberty. 
 
 Hydroa Vacciniforme of Bazin, or Summer eruption of Hutchinson, 
 seems to be an altogether different kind of affection. The eruption, 
 sometimes preceded by general malaise, accompanied by a burning- 
 sensation and local tension, is not polymorphous, but vesiculo- 
 bullous. At first tense and prominent, the small lenticular bulla? 
 spread out, become umbilicated, attain the size of a finger-nail, 
 become transformed into brownish pustules with a central depres- 
 sion and dry in crusts which leave cicatrices resembling the pits of 
 smallpox. Central necrosis is occasionally noted. 
 
 The eruption occupies the exposed regions, especially the cheeks, 
 the nose, the ears and the hands, being very rarely found elsewhere. 
 It appears in the spring, under the influence of exposure to light, 
 notably short-wave rays, as has been demonstrated experimentally. 
 The patients, as a rule, have hematoporphyrinuria. The affection 
 begins in the first few years of life, and usually ceases spontaneously 
 at the age of twenty to thirty years. 
 
 There is accordingly a hypersusceptibility to light radiations, due 
 to abnormal tissue-juices; it is an established fact that hemato- 
 porphyrin sensitizes toward the action of light. 
 
 As to the relations of Impetigo herpetiformis of Hebra-Kaposi, 
 studied in France by Dubreuilh, with herpes gestationis and Duhr- 
 ing's disease great uncertainty prevails. This very rare affection is 
 practically restricted to pregnant women, although a few cases are 
 said to have been observed in men. 
 
 The eruption consists of red and swollen nummular spots which 
 became covered with small miliary pustules, increase in size and 
 became confluent in large surfaces, crusted in the center and pus- 
 tular at the periphery. It usually starts in the inguino-crural region, 
 the umbilicus, the loins or axilla?, and may become generalized, even 
 involving the mucosa?. Severe general symptoms are present, in 
 the form of chills, remittent fever, a typhoid condition, tetany, 
 eclampsia. In 19 of 84 cases collected by Borzecki, the outcome 
 was death. 
 
 No cultures can be grown on ordinary media from the contents of 
 the pustules. If the condition is not a septicemia, but another 
 
186 BULLJE AND BULLOUS DERMATOSES 
 
 pregnancy auto-intoxication, as in herpes gestationis, it would be 
 reasonable to try injections of serum from normal pregnant women. 
 
 It is also not known at the present writing if the continuous acro- 
 dermatitis of Hallopeau and others, or recurrent phlyctenoses of the 
 extremities of Andry, are pyodermatitides favored by a predisposed 
 trophoneurotic territory, or clinical forms of 1 hihring's disease. The 
 affection begins, at any age, under the guise of a whitlow; but new 
 purulent bullne form incessantly, invading the entire finger, then 
 other fingers and the hand, in islands or over a continuous surface. 
 The other extremities are attacked in their turn. Radiating pains 
 and pruritus are present. The affection lasts for years, with 
 paroxysms, but without healing nor extending over the body. The 
 nails finally fall out (compare impetiginous onyxis); the skin 
 becomes atrophic and remains red. 
 
 Aside from this suppurative form of acrodermatitis, a vesicular 
 form has been described, characterized by isolated vesicles, on a red 
 base, incessantly reproduced on the same fingers and related to the 
 zosteriform eruptions. 
 
 CHRONIC PEMPHIGUS. 
 
 This name, or that of genuine pemphigus (pemphigus vulgaris), 
 is reserved by me, with Besnier and Brocq, for a rare and almost 
 invariably fatal progressive bullous disease, the most dangerous 
 among the great malignant skin diseases. 
 
 Symptoms. — Genuine pemphigus usually begins about the mouth, 
 the pharynx or lips, the nasal fossae [the conjunctivae], or some- 
 times on the anterior aspect of the chest. 
 
 The eruptive lesion on the skin consists of round rather large- 
 sized bullae, of nummular dimensions, tense or flaccid, with yellowish 
 or turbid contents. They develop very rapidly on the healthy skin ; 
 their base becomes reddened at the end of a few hours, or when they 
 suppurate. Whether ruptured or not, they may undergo two different 
 evolutions, either drying in crusts which are shed at the end of eight 
 or ten days and leave a red or brownish macule; or the roof of the 
 bulla becomes detached, exposing a, smooth bright red surface which 
 sometimes suppurates. They do not enlarge much, but multiply in 
 incessant new crops. 
 
 In advanced stages of the disease the erosions are slow to become 
 covered with epidermis; they run together here and there in poly- 
 cyclic, raw or crusted lesions, surrounded by bullous elevations 
 (Fig. 57) and may cover a considerable portion of the integument, 
 more or less simulating eczema or an exfoliative dermatitis. 
 
 According to the contents and the behavior of the bullae, the 
 
CHRONIC PEMPHIGUS 
 
 187 
 
 terms hemorrhagic, ulcerative, diphtheroid, gangrenous pemphigus, 
 etc., have been employed. 
 
 The eruption occupies especially the folds, the neck, the axillae, 
 the anogenital and inguinocrural regions, the umbilicus, the periph- 
 ery of the nails, as well as points subjected to pressure, such as the 
 buttocks, trochanters, scapulae, knees, heels, ears; but there is a 
 tendency to almost complete generalization. 
 
 Fig. 57. — Genuine chronic pemphigus in an exhausted old man. The eruption dates 
 a month back, the patient died less than seven weeks from the time of its onset. 
 
 In the mouth the lesions are primary or precocious, very transi- 
 torily bullous, assuming the appearance of a diphtheroid angina or 
 ulcerative membranous stomatitis, and promptly spreading to the 
 lips. The nasal, conjunctival, vulvar and other mucous membranes 
 are very often affected in a similar way. 
 
188 BULLAE AND BULLOUS DERMATOSES 
 
 At ;i certain stage of the disease Nikolsky's sign is invariably 
 present; by forcible pressure exerted on the patient's skin with the 
 pulp of the finger, the horny layers can be detached and made to 
 slip off; moreover, a moderate amount of pressure gives rise to the 
 appearance of a bulla. This sign, which indicates acantholysis, is 
 also met with in pemphigus foliaceus, in congenital pemphigus, and 
 in the grave form of Duhring's disease. 
 
 Pruritus, formication and heat sensations may he entirely 
 absent, the bullae developing without the patient's knowledge when 
 this is the case, in contradistinction to Duhring's disease. But the 
 excoriations, sores and buccal lesions cause severe pain. Adhesions 
 may develop between two mucous surfaces; serious changes of the 
 conjunctivae and cornea- may occur; the nails and hairs fall out. 
 
 - 
 
 Fig. 58. — Histology of genuine chronic pemphigus. Flaccid subcorneal bulla, very 
 recently developed, derived from the case shown in I"i<r. 57. The cavity contains 
 a sero-albuminous fluid in which float numerous white corpuscles arid a few 
 epithelial cells. The adhesion of the epidermal cells with each other is diminished: 
 on the borders of the blebs, the corneal layer tends to become detached from the rete; 
 Nikolsky's sign was present to a marked degree in this case. X 65. 
 
 The general phenomena consist of nervous depression or excite- 
 ment, anorexia, extremely rapid emaciation ; finally diarrhea, 
 vomiting, cachexia and sometimes a transformation into pemphigus 
 foliaceus, lead to death. Fever has been noted, being sometimes 
 accounted for by the existence of abscesses, ulcers, or sloughs. 
 
 The course is rapidly progressive. The fatal termination takes 
 place in three to eighteen months, rather less than more, through 
 cachexia or an intercurrent infection. 
 
 Cases have been reported, and have come under my personal 
 observation, possessing all the characteristics of true pemphigus, 
 instead of Duhring's disease, which nevertheless terminated in 
 recovery or in a complete remission lasting several years. We are 
 obliged therefore to admit the existence of a benign form. 
 
 Diagnosis. This is usually very precarious at the onset, and it 
 has well been said that there exist no two exactly similar cases of 
 
PEMPHIGUS FOLIACEUS 189 
 
 genuine pemphigus. The most experienced dermatologists some- 
 times hesitate in the presence of the early lesions which have the 
 appearance of stomatitis, angina, toxidermia, hydroa, or Duhring's 
 disease. In the developed stage, the clinical picture becomes clear 
 and more or less approximates the description given above. 
 
 Pathological Anatomy. — The bulla? are so fragile that it is difficult 
 to obtain unruptured specimens for examination. The cavity may 
 be subcorneal, intramalpighian, or subepidermic. Underneath the 
 bulla, the derma is edematous, but contains only a few wandering 
 cells. 
 
 The subjoined figure (Fig. 58) gives an idea of these lesions. 
 
 Eosinophils are not usually found either in the fluid contents of 
 the bullse or in the neighboring tissues. The contents are sterile or 
 enclose microbes of secondary infections. Blood cultures are usually 
 negative. The investigations of Lipschutz point to protozoa as 
 the responsible agents. [?] 
 
 Etiology and Character. — Chronic pemphigus attacks especially 
 weakened exhausted individuals past the age of forty years, some- 
 what more frequently males. The Jewish race seems to be pre- 
 disposed to it. 
 
 The disease is not contagious, and there is nothing to prove its 
 infectious character. It may equally well be claimed to result from 
 a severe affection of the central nervous system, or possibly from 
 an auto-intoxication. 
 
 Treatment. — The external treatment is that of the other bullous 
 skin affections. Internal medication has for a long time been con- 
 sidered absolutely ineffective, so that the patient's strength was 
 simply kept up by means of nourishing food, fresh air, tonic medic- 
 inal agents, strychnin, etc. Recently, various authors have re- 
 ported improvement and even cures, by means of quinin (1.0 to 2.5 
 gm. daily), antipyrin, arsenic, and especially arsenobenzol, as well 
 as by injections of normal serum. These therapeutic measures 
 should accordingly be resorted to, instead of considering the situ- 
 ation as hopeless. 
 
 PEMPHIGUS FOLIACEUS. 
 
 This term is applied, since Cazenave, to a skin disease which 
 begins with pemphigus and becomes transformed into an exfoliative 
 erythroderma. It is difficult to give a clear description of its 
 extremely variable clinical picture and course. The onset may be 
 that of chronic pemphigus, or more rarely Duhring's disease; or 
 there may be a bullous dermatosis impossible of classification, 
 with rare and discrete, then numerous and close-set bulla?, often 
 remarkably flaccid. Depending on its course, pemphigus foliaceus- 
 is called secondary or primary, 
 
100 
 
 BULL.E AND BULLOUS DERMATOSES 
 
 In the transition-stage, no more normal epidermis is formed at 
 the points occupied by the bullae, but instead lamellar, leaf-like, 
 moist scales or crusts, which cover large red surfaces, sometimes 
 extending over almost the entire body (Fig. 59). This epidermis 
 is incapable of forming the roof of blisters and these are replaced by 
 oozing spits from which the scales arc easily detached. Under the 
 scales or at the macerated points, a highly offensive epidermic mass 
 
 foliaceus of four ye 
 twenty-five years. 
 
 :i woman 
 
 a god 
 
 is found, made up of isolated Malpighiaii cells. On the borders of 
 the squamous surfaces is seen a bullous margin, especially in the 
 vicinity of the hands and feet which sometimes escape. 
 
 Finally, the lamellar exfoliation becomes general and resembles 
 that of the other erythroderniias; it is sometimes so abundant that 
 handfuls of epidermal structures can be picked up from the patient's 
 bed. However, it usually retains a peculiar moisture. 
 
CONGENITAL PEMPHIGUS 191 
 
 The skin is a dark or brownish red, thinned and tense, or not 
 infrequently papillomatous; fissures appear in the articular folds 
 and ectropion develops on the eyelids. The hairs of the scalp and 
 body become scanty; the nails become streaked and hooked and may 
 fall out. The mucous membranes usually remain intact. 
 
 Pemphigus foliaceus is the disease in which Nikolsky described 
 the sign of easy detachability of the horny layer, which he believed 
 to be pathognomonic. 
 
 Pruritus and heat sensation are not prominent, except period- 
 ically. The urine is scanty and the urea and nitrogen index is 
 always low. 
 
 The disease is protracted, sometimes lasting five to ten years, 
 often only two or three years. It regularly terminates in death, 
 due to digestive disturbances, especially diarrhea, marasmus, or 
 intercurrent complications. 
 
 The pathological anatomy has yielded divergent findings. The 
 epidermis was found to be tense and thinned or there were greatly 
 elongated papillse and intrapapillary buds, with dermic and epidermic 
 edema and abundant exocytosis. The condition of the granular 
 layer is variable. Eosinophilia is noted in the blood. Various 
 lesions of the nerve centers have been described, but are inconstant. 
 
 Pemphigus foliaceus is encountered in both sexes, among adults 
 in a state of physical or psychic deterioration. 
 
 We do not know if it is of nervous, toxemic, hematodermic, or 
 other origin. It seems that certain cases can be interpreted as 
 malignant exfoliative herpetides, secondary to a pemphigus; the 
 appearance of other cases is that of a distinct pathological entity. 
 
 The treatment must follow that of the other bullous skin diseases 
 and the erythrodermas. 
 
 CONGENITAL PEMPHIGUS. 
 
 This is a cutaneous malformation rather than a disease ; it is very 
 rare, usually familial or hereditary, as a rule congenital, but occasion- 
 ally does not mainfest itself until late childhood, or still later. From 
 various sources attention has been called to the apparent influence 
 of consanguinity of the parents. 
 
 It consists of a predisposition of the skin and sometimes of the 
 mucous membranes, to react in the form of bullse toward all trau- 
 matisms, pressures, or even slight bruises. 
 
 Two degrees are known, and by some are considered as separate 
 types of the disease: The first, epidermolysis hereditaria bullosa 
 of Kobner, or simple traumatic hereditary pemphigus, consists 
 merely of a tendency to the formation of tense, subcorneal, serous 
 or sero-sangumolent blisters; these develop in the healthy skin, 
 
192 HI 1.1..K AND BULLOUS DERMATOSES 
 
 under the influence of blows, or pressure by the clothing, shoes, 
 etc. The feet, hands, wrists, elbows, knees, etc., and even the 
 buccal mucosa arc affected with blebs, which come on without pain 
 in less than an hour after the traumatism and which heal very 
 readily, provided infection does not occur. 
 
 In the second, the grave and dystrophic form — "Pemphigus 
 successif a Kystes epidermiqujes" or congenital pemphigus with a 
 tendency to cicatrization — an apparently spontaneous production 
 of more or less numerous bullae is noted at various points of the 
 limbs and body, within a short time after birth. There is a constant 
 succession of these bullae, especially in regions exposed to pressure, 
 on the extremities, the ears, the knees and elbows, even on the 
 mucous membranes. 
 
 Gradually the skin of certain regions, principally that on the 
 back of the hands and the joints of the fingers, the elbows and knees, 
 etc., becomes atrophic or cicatricial, thin like onion peel, of a 
 brownish purplish-red color. An enormous number of very small 
 white opaque granules are seen; these are milium cysts. The nails 
 undergo various deformities, or fall out permanently. 
 
 The microscope discloses atrophy of the derma with disappear- 
 ance of the papillary body and shows that the cysts are dilatations 
 of the sweat ducts with corneal contents or more rarely follicular 
 cysts. Similar miliary cysts and atrophic changes are noted in some 
 cases of 1 hihring's diseases. 
 
 In the congenital forms of pemphigus, Xikolsky's sign of easy 
 detachability of the horny layer is almost invariable present. In 
 certain cases, a combination has been demonstrated between 
 congenital pemphigus and various forms of congenital ichthyosiform 
 hyperkeratosis. On the other hand, Nicolas, Montot and Charlet 
 have described a type with chronic and progressive vegetative 
 ulcerations. 
 
 'Phe pathological predisposition usually diminishes with the 
 advance of years; or it may become limited to some particular 
 region. 
 
 The patient must be cautioned against all exposure to traumatism. 
 Protective dressings and tonic internal medication are indicated. 
 
 PEMPHIGUS HYSTERICUS. 
 
 Hysterical pemphigus does not exist, as has been shown by 
 investigations and conclusive discussions. 
 
 1 fnder tins name, or under that of drginal or chlorotic pemphigus, 
 were designated attacks of bullous eruptions, hemorrhagic, pustular 
 or sloughing, which occurred in nervous girls or young women of 
 peculiar character. 
 
PEMPHIGUS HYSTERICUS 193 
 
 The lesions, often of an irregular or elongated shape, are^dis- 
 tributed in a remarkable fashion, sometimes with suspicious regular- 
 ity. They appear one by one, or in small numbers at a time, 
 throughout a period of several months or years. The course is 
 invariably benign. However, through their extent, numbers and 
 sometimes gangrenous character, the lesions may cause actual 
 mutilations. 
 
 In all cases which could be seriously investigated, where the 
 patient was carefully watched, or when, for example, a sealed 
 occlusive dressing was applied over the affected region, the condition 
 could always be traced to malingering. The lesions are burns or 
 cauterizations by chemical or medicinal agents and are produced by 
 the patient herself under the influence of a special mental state which 
 has been named mythomania or pathomania. These are cases of 
 dermatitis artefacta. The truth of Babinski's statement is beyond 
 question, that hysteria is incapable of giving rise to trophic dis- 
 turbances of the skin. 
 
 The exposure of trickery demands some tact on the part of the 
 physician, whose suspicions are often repudiated by the patient's 
 environment. But when the proof of the fraud has once been made, 
 the so-called eruption subsides of its own accord. 
 
 13 
 
CHAPTER XI. 
 KERATOSES. 
 
 HYPERKERATOSES AND DYSKERATOSES. 
 
 The name keratosis is applied to a dermatological lesion which 
 consists in moderate thickening of the horny layer; hyperkeratosis 
 means a considerable hyperplasia of this layer; dyskeratosis is a 
 pathological process in which a disturbed keratinization terminates 
 in the formation of an abnormally constituted corneal layer, with 
 thickening in some of the cases and disintegration in others. 
 
 Under normal conditions, the horny layer is formed by the super- 
 posed layers of lamellar cells, which are composed of keratin and 
 loaded with fat, but have neither protoplasm nor nuclei. These 
 corneal cells represent the ultimate stage of the process of epidermic 
 development. Originating through multiplication of the constit- 
 uents of the basal layer, the Malpighian cells are gradually pushed 
 up by the newly generated cells and reach the granular layer where 
 they take up eleidin or keratohyalin, after which they suddenly 
 undergo the transformation known as keratinization. 
 
 The corneal cells adhere to each other and persist a certain time 
 at the epidermal surface, where they constitute a resistant, supple, 
 and only slightly permeable protective covering. Being no longer 
 alive, the horny cells are incapable of vital reaction against irritants 
 of any kind and are finally shed. 
 
 The thickness of the normal horny layer varies slightly in diffei- 
 ent individuals and greatly in different regions of the body. 
 
 I shall begin with a discussion of the cutaneous affections char- 
 acterized by thickening of the horny layer, leaving to the end of 
 the chapter the conditions designated dyskeratoses. 
 
 KERATOSES AND HYPERKERATOSES. 
 
 In the cutaneous affections characterized by a thickening of the 
 horny layer the degree' of this hyperplasia is variable — being 
 slightly marked and accompanied by a, powdery or scurvy desqua- 
 mation in kerosis and pityriasis simplex or considerable, often 
 producing a. genuine carapace, resistant and liable to crack, in the 
 iclitliyosiforni hyperkeratoses and numerous keratodermias; in 
 ichthyosis, all degrees arc met with, from simple xerodermia to the 
 most pronounced sauriasis. 
 
KERATOSES AND HYPERKERATOSES 195 
 
 In a general way, when the horny layer is very hyperplastic, the 
 granular layer and the mucous body are, as a rule, likewise of very 
 abnormal thickness; the derma itself is usually congested and 
 there is an obvious tendency toward the production of papillary 
 elevations or vegetations. 
 
 The name of verrucosa state is applied to the common combination 
 of keratosis with the vegetative process (XII). 
 
 The term keratoma is sometimes applied to a circumscribed 
 hypertrophy, forming a tumor, such as cutaneous horns. 
 
 From the point of view of the distribution of the lesions on the 
 surface of the integument, a distinction must be made between 
 the following groups : 
 
 1. Diffuse and generalized keratoses, spreading over almost the 
 entire body, or at least over large surfaces, although with evident 
 regional predilections. 
 
 In this group I shall describe kerosis, pityriasis simplex, ichthyosis 
 and the generalized and partial ichthyosiform hyperkeratoses. 
 
 2. Circumscribed keratoses, composed of distinctly limited kera- 
 totic spots or surfaces; some are scattered without apparent order, 
 others assume a regional or symmetrical arrangement, while a few 
 are even distinctly systematized. 
 
 This group comprises: keratotic neii, linear nevi, senile warts, 
 senile keratosis and a few analogous affections. 
 
 It is not superfluous to point out that keratotic lesions in scat- 
 tered spots or on more or less extensive surfaces, may be present or 
 simulated, in a large number of skin affections. But corns, flat 
 warts and common warts have been described elsewhere. The 
 cutaneous dystrophies such as acanthosis nigricans, which is vege- 
 tative and xeroderma pigmentosum, in which the lesions of the 
 derma are important and essential, likewise belong in other chapters. 
 
 As regards the patches of psoriasis inveterata and ostreacea, 
 lichen hypertrophicus, lupus erythematodes of the type of "herpes 
 cretace," tuberculosis verrucosa, the angiokeratomas, etc. — the 
 thickening of the horny layer here is secondary to a definite process 
 of different character. They are here mentioned only from the 
 viewpoint of the differential diagnosis. 
 
 3. Regional keratoses proper, which owe very peculiar character- 
 istics to their topographical localization. Such are notably the 
 palmar and plantar keratoses, for which I reserve the name of 
 keratoderma. 
 
 Although the epithelium of the mucous membranes, more par- 
 ticularly that of the mouth, does not, under normal conditions, 
 become keratinized like the epidermis, local pathological lesions are 
 observed which are properly entitled to the name of keratoses of the 
 mucosce. 
 
196 KERATOSES 
 
 KEROSIS. 
 
 The chronic pathological condition of the skin which I have 
 named kerosis, is characterized clinically by: (1) Dirty yellowish 
 or grayish coloration; (2) accentuation of the pilo-sebaceous pores; 
 (3) a slight thickening of the integument. 
 
 The anatomical lesions are: A slight diffuse hypertrophy of the 
 horny layer, with a tendency to fine desquamation and a modifi- 
 cation, of unknown character, of its fat content; hyperkeratosis 
 of the pilo-sebaceons orifices. 
 
 This dystrophy finds its proper place in the group of. the diffuse 
 keratoses. It is usually misinterpreted and confused, erroneously 
 in my opinion, with seborrhea, which constitutes merely a complica- 
 tion. 
 
 Although of slight importance in itself, kerosis acquires clinical 
 interest because it furnishes the necessary or ordinary substratum 
 for several of the most common cutaneous affections. Such are 
 certain pityriases, seborrhea, certain alopecias and hypertrichoses, 
 hyperidrosis oleosa, some acnes, rosacea, many cczonatides. 
 
 The kerotic pityriasis will be described in the following paragraph. 
 For the other kerotic affections, the reader is referred to the chapters 
 dealing with the follicnloses, trichoses, hidroses and the erythemato- 
 squamous dermatoses. 
 
 The topographical distribution of kerosis is both diffuse and 
 regional. It occupies by predilection and to the highest degree, the 
 center of the face, especially the nose and the nasogenial furrows, 
 and the seal]); very frequently also the forehead, the temples, the 
 chin, the nape of the neck; on the trunk, it affects especially the 
 pre-sternal oval and the interscapular groove, spreading more or less 
 around the middle line. It often covers the shoulders, the entire 
 thorax, uniting at the sacrum behind, at the umbilicus in front; it 
 is not uncommon on the pubis, the genital organs, the intergluteal 
 fold, in the large articular folds and even on the palms of the hands. 
 
 The following parts invariably escape: the front of the neck, the 
 extensor surface of the limbs, the buttocks and the forearms and 
 legs as a whole. 
 
 It will be noted that, this distribution is practically the opposite 
 of what is seen in ichthyosis. 
 
 On this territory, the various manifestations and complications 
 of kerosis are not produced haphazard, but each has its preferred 
 or exclusive regions. 
 
 Numerous factors play a role in the etiology of kerosis. This 
 anomaly is so widely distributed in civilized countries and in its 
 mild degrees so close to the physiological condition, that one hesi- 
 tates to define it as a disease. Certain individuals, more or less 
 
KEROSIS 197 
 
 numerous according to the race, are immune. Direct heredity, 
 or the influence of poor health or bad hygiene of the parents, 
 constitute the fundamental conditions of kerosis. The establish- 
 ment of the genital functions and sexual disturbances on the one 
 hand, unhygienic diet on the other, in the form of a hypernitrog- 
 enous diet, abuse of stimulants, coarse food, insufficient mastication, 
 abnormal fermentations, constipation, etc., are common factors, 
 the individual effect of which is not easily determined. 
 
 External local irritation, reflex circulatory disturbances con- 
 nected with affections of the mucous membranes, play a much less 
 prominent part. 
 
 By a certain school, the manifestations of kerosis are interpreted 
 as directly microbic, each one, according to Sabouraud, being refer- 
 able to a special variety of microbe or an association of varieties. 
 The presence of microorganisms is indeed undeniable, but their 
 pathogenic action has not been demonstrated. 
 
 At any rate, kerosis and its manifestations follow a certain law of 
 evolution in connection with the age of the individual. Dry pity- 
 riasis of the hairy scalp, appearing at the age of six to ten years, 
 becomes transformed about or after puberty into oily pityriasis, 
 seborrhea developing at the same time. Acne juvenilis flourishes 
 from the age of fifteen to twenty-five years. Calvities gravis 
 begins at twenty-five years, or less. . Rosacea may be premature, or 
 be delayed until about the age of forty-five years. In aged indi- 
 viduals, the sequelae of kerosis become attenuated and extinct, unless 
 it be held accountable for seborrheal warts and senile keratosis. 
 
 It is quite possible that the vernix caseosa, or the greasy epidermic 
 covering of some infants at birth and the so-called acne miliaris of 
 the newborn which may accompany it, represent the first mani- 
 festation of kerosis. This would be an additional reason for regard- 
 ing the latter, accepting the views of Jacquet, as closely related to 
 sexual development. As a matter of fact, kerosis has two periods 
 of florescence, that of the genital wave at the time of birth, and 
 that of puberty; and a period of decline, when sexual life is 
 restricted. 
 
 The treatment of kerosis must consist in the first place in cor- 
 recting all hygienic deficiencies which may be present. It may 
 be necessary to administer alteratives, such as phosphates, cod- 
 liver oil and especially arsenic on account of its keratoplasty 
 properties. 
 
 Mineral springs, with sulphur, arsenic or sodium chloride water, 
 are especially indicated. 
 
 Locally, sulphur in the form of sulphurous or sulphur lotions, soaps, 
 glycerolates, pastes or salves, but also the tars, camphor, calomel, 
 reducing agents in general, are very serviceable. 
 
198 KERATOSES 
 
 With perseverance, it will almost invariably prove possible to 
 obliterate the principal kerotic manifestations and to restore the 
 skin, if not to normal, at least to a condition very close to normal; 
 relapses, however, are common. 
 
 PITYRIASIS SIMPLEX. 
 
 The name of pityriasis simplex is applied to a non-inflammatory, 
 scurfy, bran-like desquamation of the horny layer. 
 
 The term pityriasis, derived from the Greek irlrvpov meaning 
 "bran," is on the other hand applied to various pathological con- 
 ditions which have nothing in common with the subject under 
 discussion. 
 
 Pityriasis versicolor is a specific parasitical disease of the epidermis; 
 pityriasis rosea of Gibert is an erythemato-squamous dermatosis; 
 pityriasis rubra pilaris belongs rather with the folliculoses; pityriasis 
 rubra is an erythroderma. 
 
 Pityriasis simplex must be distinguished from the pityriasiform 
 desquamations following upon an inflammation, such as may be 
 observed after the erythemas, eruptive fevers, pyodermatitides, 
 or in the course of certain trichophytoses and especially of eczemas. 
 In these cases, the desquamation almost invariably results from 
 the phenomenon known as parakeratosis. 
 
 In pityriasis simplex, on the contrary, the keratinization of the 
 epidermis is complete, and takes place, at least apparently, in a 
 normal manner; but the corneal epithelium is thickened and peels 
 off in scurfy lamellae or scales, instead of in a fine powdery and 
 imperceptible form as on the healthy skin. 
 
 In accordance with this definition, pityriasis simplex is one of tin- 
 most common manifestations or consequences of kerosis. Hence 
 there is nothing to add in regard to its etiology, to what has been 
 stated concerning this dystrophy; but I wish to emphasize again 
 the influence of age upon its course. 
 
 Those authors who include the entire picture of keratosis under 
 the incorrect name of "seborrhea," have been led, after Ilebra, to 
 consider pityriasis simplex as a "seborrhea sicca;" but this expres- 
 sion is in every way inadmissible. 
 
 Pityriasis simplex is almost exclusively met with, or at any rate 
 decidedly predominates in the hairy regions and especially on the 
 seal]), where it is designated as pityriasis capitis. Next in order, it 
 affects the beard, the pubis, the hairy regions of the thorax and 
 sometimes the limbs. 
 
 Two varieties can be distinguished, which are connected, how- 
 ever, by a series of intermediary forms. 
 
PITYRIASIS SIMPLEX 199 
 
 Pityriasis sicca is a condition in which there is an incessant 
 reproduction of dry white or grayish lamellae, called dandruff by 
 the laity. An extreme degree was formerly described as "teigne 
 amiantacee (asbestos-like tinea), a name suggested by Alibert. Its 
 mild degrees blend with the physiological desquamation which is 
 encountered on any neglected scalp or improperly kept beard and 
 even on the entire body of bedridden patients. 
 
 In pityriasis oleosa, which often follows upon the preceding, the 
 scales are oily, greasy, yellowish, sticky; but it is noteworthy that 
 they occur on a skin of normal coloration, without pathological 
 redness. 
 
 The oily character of this pityriasis might appear to be referable 
 to its association with seborrhea (supra-seborrheal pityriasis of 
 Sabouraud). This combination is frequent, but not constant. 
 There is an oily pityriasis without seborrhea in the same location ; 
 the fat is derived from the keratinization itself. 
 
 As regards the steatoid pityriasis of Sabouraud, this is not a 
 simple pityriasis, but an eczematide on a kerotic soil. It furnishes 
 no scales, but crusts, the consistence of which is due to dried serum; 
 the skin where they occur is pink and moist and pruritus is often 
 present. The so-called milk-crusts of children usually belong to this 
 variety. 
 
 Although we are not justified, in my opinion, in regarding pity- 
 riasis simplex as of parasitical origin, it is necessary to point out 
 the remarkable abundance of microorganisms in its scales. The 
 predominating parasite is the spore of Malassez, or bottle bacillus; 
 it is very polymorphous, rather large, assumes the forms of 
 yeasts, but has so far resisted all attempts at artificial culture. It 
 is associated with the bacillus of seborrhea in oily pityriasis, and 
 with various cocci, chiefly the polymorphous coccus of the skin 
 (coccus cutis communis) in the so-called steatoid pityriasis. 
 
 Pityriasis simplex is merely an unpleasant, hardly a troublesome 
 affection, in itself; it is feared only on account of the alopecia and 
 baldness which are attributed to it. Aside from this, it exposes 
 to the danger of eczematides and must therefore be systematically 
 controlled. 
 
 The treatment of pityriasis capitis requires in the first place local 
 measures; frequent washing with sulphur, naphthol or tar-soaps, 
 or better with a decoction of quillaya bark [saponin], aqueous 
 solutions with sulphur, coal tar, etc., or alcoholic and ethereal, 
 mercurial, naphtholated or compound lotions, several formulae for 
 which may be found at the end of this book. Ointments are not 
 agreeable to the patient, but it is advisable to employ them in 
 severe cases, at least for nocturnal treatment. 
 
 The general hygiene and that of the hair and its arrangement 
 
200 KERATOSES 
 
 must be properly regulated. Analogous measures are applicable 
 in pityriasis of the beard or other regions. 
 
 Pityriasis Simplex of the Face and Hairless Parts is limited to 
 children and youthful individuals with delicate skins. It is found 
 around the mouth, on the cheeks, the chin, the front of the neck, 
 and sometimes on the trunk and the limbs. It appears in the form 
 of rounded, oval spots or more or less distinctly outlined polycyclic, 
 scurfy or furfuraceous areas, with a normally colored or slightly 
 pinkish surface, ligher than the background when the complexion 
 is tanned or sun-burnt. 
 
 This superficial dermatosis is contagious and even epidemic in 
 groups of children. It may coincide with impetigo and Sabouraud 
 regards it as a dry impetiginous epidermatitis, due to staphylococci. 
 It may become eczematized and should probably be classified with 
 the mild eczematides. 
 
 It is very readily curable by means of mild sulphur or white 
 precipitate ointments, etc. 
 
 ICHTHYOSIS. 
 
 Ichthyosis is a diffuse generalized keratosis which is never con- 
 genital but which manifests itself at an early age and persists 
 throughout life. It is usually considered a malformation of the 
 skin. 
 
 Symptoms. — The ichthyotic skin is dry and scaly. In typical 
 cases of moderate severity, the integument is roughened, parch- 
 ment-like, covered with dry scales which have been compared 
 with fish scales; they are thin, white or brownish or gray, more or 
 less easily detached and constantly renewed. 
 
 Many degrees or objective varieties of ichthyosis can be described : 
 In xeroderma the skin is merely dry and the desquamation is 
 powdery, almost imperceptible; "ichthyosis nitida, or nacreous 
 ichthyosis, with thin and silvery lamelhe, is the most common form; 
 in ichthyosis nigricans or black ichthyosis, the scales are of a dark 
 color; they are large and polygonal in ichthyosis serpentina; large, 
 thick and resembling the skin of the crocodile, in sauriasis; finally, in 
 ichthyosis hystrix, prominent warty or pointed horny excrescences 
 are seen, suggestive of the porcupine's skin. 
 
 The two last named varieties are sometimes combined under the 
 name of ichthyosis cornea; it is very probable that they do not 
 legitimately belong to ichthyosis but to the ichthyosiform hyper- 
 keratoses, which will be discussed further on. 
 
 Ichthyosis is always symmetrical and is most marked on the 
 extensor surface of the limbs, especially the elbows and knees i Fig. 
 GO), but also the trunk and to a less degree, the head and hands and 
 
ICHTHYOSIS 
 
 201 
 
 feet. The face is, as a rule, only slightly xerodermic; the scalp is 
 pityriasic; the palms of the hands and the soles of the feet are very 
 often dry and wrinkled like the hands of washerwomen. 
 
 On the other hand, the articular folds, axillae, elbow bends, 
 popliteal spaces, intergluteal fold, groins and the genital organs 
 are always more or less free, in contradistinction to what is seen in 
 the ichthyosiform hyperkeratoses. Lesions of mucous membranes 
 are altogether absent. 
 
 On passing the finger-nail or some pointed object over the skin of 
 ichthyotic patients, a white powdery track is left behind; the skin 
 often appears tense and when it is grasped between two fingers the 
 papillary body folds up superficially over the derma. The hairy 
 system may be normal or is imperfectly developed; the downy 
 hairs of the extensor surfaces are very fine, resembling lanugo and 
 sometimes appear to be thinned; the co-existence of keratosis 
 pilaris is invariable. 
 
 Fig. 
 
 -Ichthyos 
 
 nitida in a youth aged sixteen years. Note the white mark left 
 by the garters above the knees. 
 
 The nails are normal, or rarely dry and brittle. The sebaceous 
 and sweat secretions are greatly diminished; heat or violent exer- 
 cise may cause sweating in mild cases of ichthyosis and the affec- 
 tion will then become attenuated or disappear, as for instance, in 
 the summer. Ichthyotic patients are usually thin, poorly devel- 
 oped and of slight resistance. 
 
 Pruritus is not a feature in the clinical picture of ichthyosis, 
 unless it is complicated by eczema, which is rather common. This 
 eczematization is observed especially in persons neglectful of 
 cleanliness and those exposed to artificial dermatitis, or even, it 
 has been claimed, without an apparent local cause; the attacks 
 may be obstinate and recurrent but always represent merely a- 
 superadded complication. 
 
202 KERATOSES 
 
 Ichthyosis is never strictly congenital; it develops gradually and 
 is usually not observed until the third year of life, though some- 
 times as early as the third or fourth month; often the date of onset 
 cannot be accurately determined. It may become attenuated at 
 the time of puberty, but as a rule it persists until death. Hebra 
 and Hardy assert that it may disappear after eruptive fevers, but 
 this is extremely doubtful. 
 
 The name of ichthyosis tabescentium, desquamation of cachectics, 
 and senile ichthyosis has been applied to a state of diffuse atrophy, 
 with dryness of the skin and ichthyosiform desquamation, which 
 develops in weak old people and bedridden invalids. 
 
 It is not known if the pathological condition in these cases is 
 always identical and how it is related to ordinary ichthyosis. 
 
 Pathological Anatomy. — The horny layer is always more or less 
 thickened; the granular layer is diminished or absent in the variety 
 nitida, but there is no complete parakeratosis; the mucous body 
 is rather thin and tense. The papillae are less developed than 
 normal. The papillary body and the chorion are almost invariably 
 found to contain a moderate infiltration of round cells and mast 
 cells around the vessels; this fact has led Unna and Tommasoli to 
 consider ichthyosis as an inflammatory skin disease. The pilo- 
 sebaceous follicles present the lesions of keratosis pilaris. Various 
 lesions of the sweat glands have been reported. 
 
 The changes attributed to the hystrix form are identical with those 
 of ichthyosiform hyperkeratosis and of the hyperkeratotic nevi; so 
 that some doubt prevails as to the existence of a true ichthyosis 
 hystrix. 
 
 Etiology. — Ichthyosis, except in its mildest form, is not very 
 common; its extreme degrees are actually rare. It is a hereditary 
 malformation in one-fourth of the cases, familial in one-half of 
 the cases, according to Gassmann; the transmission is irregular 
 and may skip a generation. It is not certain and even rather 
 improbable that alcoholism, syphilis or tuberculosis of the parents 
 create a predisposition to the disease. Both sexes are equally 
 affected. 
 
 Diagnosis. — Mild xeroderma with or without keratosis pilaris, 
 may be misinterpreted or confused on superficial examination 
 with pityriasis simplex, kerosis, the post-eruptive desquamations, 
 desquamations of cachectics, etc. When the onset of the affection 
 can be determined, the point will be settled at once. 
 
 In psoriasis, in the dry eczemas and in pityriasis pilaris, the skin is 
 red. Psorospermosis, named ichthyosis follicularis by J. C. White, 
 is quite characteristic. 
 
 Ichthyosis must be differentiated especially from generalized 
 ichthyosiform hyperkeratosis (congenital ichthyosis of certain 
 
ICHTHYOSIFORM HYPERKERATOSES 203 
 
 authors), and from regional or very extensive systematized hyper- 
 keratotic new,, many cases of which have been described under the 
 names of ichthyosis partialis, ichthyosis hystrix, etc. 
 
 Treatment. — Although the disease is incurable, the patients can 
 be greatly relieved by maintaining their skin in a clean and supple 
 condition. Arsenic seems to be of little use; cod-liver oil is to be 
 recommended; thyroid medication may be cautiously tried. 
 
 The external treatment, however, is of the greatest importance. 
 Repeated and prolonged baths, washing with soap, steam baths, 
 on the one hand and daily inunctions with vaseline, glycerin, fatty 
 substances or various salves, on the other, will give the skin in a 
 short time a nearly normal appearance in cases of moderately 
 severe ichthyosis. The same measures must be insisted upon in the 
 severe types. It is necessary to regulate the treatment in a given 
 case in such a way as to keep up the results attained. 
 
 ICHTHYOSIFORM HYPERKERATOSES. 
 
 Under this heading must be grouped some interrelated dermatoses 
 which differ from ichthyosis by the following characteristics: 
 
 They may be strictly congenital or their appearance may be 
 delayed for a shorter or longer time after birth; they usually take 
 a progressive course; hyperkeratosis is more pronounced than is 
 ichthyosis and is accompanied by a marked redness of the skin 
 which has led to the name of ichthyosiform erythroderma; anidrosis is 
 absent or may be actually replaced by hyperidrosis ; far from spar- 
 ing the articular folds, the lesions on the contrary are especially 
 well developed in these regions; their histological structure is alto- 
 gether different. 
 
 A distinction is made between a generalized form, to be described 
 next, and circumscribed forms, which will be discussed in the 
 succeeding paragraphs. 
 
 Generalized Ichthyosiform Hyperkeratosis. — This is often named 
 fetal, intra-uterine or congenital ichthyosis, for it is always present 
 at the time of birth. Two degrees of the affection may be dis- 
 tinguished. 
 
 The severe type is incompatible with life; it has been referred to 
 in the chapter on the erythrodermias. It represents a diffuse con- 
 genital malignant keratoma. 
 
 The benign type, distinctly separated from ichthyosis by Unna 
 under the name of congenital hyperkeratosis, is characterized by a 
 more or less severe and universal redness of the skin which is con- 
 tracted and covered with large thick, polygonal, brownish scales 
 resembling the scales of sauriasis, very adherent, but capable of 
 being detached in a single piece by traction or maceration (Fig. 61). 
 
204 
 
 KERATOSES 
 
 The face is affected; it is pinkish and scaly; ectropion is usually 
 present. The articular folds are the seat of horny, blackish, 
 papillary excrescences. The palmar and plantar regions present 
 the appearance of hereditary keratoderma. The hairy scalp is 
 covered with a sebaceous coat. Brocq observed that in certain 
 
 I [G. 61. < generalized 
 Note the lizard-like aspect oi the 
 popliteal spaces. 
 
 ■perkeratosis in a girl aged eight years, 
 [tegument and the horny vegetations in the 
 
 cases, which he calls ichthyosiform congenital erythroderma with 
 hyper-epidermatro / phy, the hairs and nails grow two or three times 
 as rapidly as in normal individuals. 
 
 Especially in the first years, occasional crops of bullae may be 
 observed on the limbs and on the trunk; I have shown that these 
 bullae are auto-inoculable; they probably represent merely an 
 
ICHTH YOSIFORM H YPERKERA TOSES 
 
 205 
 
 impetigo, favored by the cracking of the epidermis (Fig. 62). All 
 the symptoms, especially the redness, become attenuated with age. 
 The majority of cases described under the names of ichthyosis 
 cornea, sauriasis, ichthyosis hystrix, were in reality ichthyosiform 
 hyperkeratosis. 
 
 Fig. 62. — Generalized ichthyosiform hyperkeratosis in a boy aged thirteen years. 
 External surface of right knee. The horny verrucous covering has been detached in 
 places; at the level of the head of the fibula a bulla is seen, resulting from an experi- 
 mental auto-inoculation. 
 
 The pathological anatomy shows lesions altogether different from 
 those of ichthyosis. The horny layer is enormously thickened and 
 arranged like shingles on the acuminate protuberances; it contains 
 considerably less fat than in the normal condition. The granular 
 layer is markedly hypertrophied. The rete is thickened. The papillse 
 are greatly elongated and irregular. Perivascular infiltration is not 
 constant. 
 
 Partial Ichthyosiform Hyperkeratoses. — Clinical observation 
 and histology are in accord as to the relation with ichthyosiform 
 hyperkeratosis, of familial keratoderma or Meleda disease, which 
 seems to represent merely a regional and partial variety of this 
 affection (p. 211). 
 
 Notwithstanding its very remarkable course, it seems justifiable 
 to connect with ichthyosiform hyperkeratosis also the rare disease 
 symmetrical erythrokeratoderma, especially since it may become 
 associated with familial keratoderma (Brocq and Dubreuilh). 
 
206 KERATOSES 
 
 This uncommon skin affection, a typical case of which was re- 
 ported by me in 1911, the face and upper part of the trunk alone 
 escaping, appears after birth in the form of spots or isolated patches 
 which spread rather rapidly and finally invade almost the entire 
 internment; the keratotic surfaces may become warty and give rise 
 to genuine cutaneous horns. 
 
 All the hyperkeratoses of this group, generalized or circum- 
 scribed, probably represent cutaneous malformations of the same 
 kind as nevi; their sometimes delayed appearance, their symmetry 
 and their extensive character, do not militate against this view. 
 There are reasons for the belief that consanguinity of the parents 
 and heredity play a certain part in their etiology. 
 
 CIRCUMSCRIBED KERATOSES. 
 
 Keratotic Nevi. — As with nevi in general, these may exist at birth, 
 or develop in the course of childhood or even later. They appear 
 in the form of spots, elevations or verrucosities which gradually 
 become covered with a more or less thick coating of horny tissue. 
 
 Hyperkeratotic and Varicose Nevi. — Hyperkeratotic and varicose 
 nevi may be single or multiple, limited or very extensive, situated 
 at any point of the integument. Some are regional and occasionally 
 symmetrical, occupying for example certain articular folds. Others 
 are covered with such a thick accumulation of horny substance as 
 to constitute a genuine cutaneous horn, resembling a small ram's 
 horn. 
 
 Linear Nevi. — Linear nevi constitute a very peculiar systema- 
 tized form of hyperkeratotic nevi. The verrucosities, of a gray, 
 brown or black color, are arranged in continuous or interrupted 
 streaks of great length and variable width, often in very regular 
 patterns. Sometimes unilateral, in other cases symmetrical, these 
 nevi are made up by a single streak or several streaks following a 
 parallel course. I have repeatedly observed the entire body, includ- 
 ing the limbs and the face, to be covered by linear designs of this 
 kind (Fig. I'm). On the limbs the streaks are longitudinal, often 
 partially spiral. On the trunk, they are horizontal or rather oblique 
 and frequently present angular inflections, forward and backward, 
 in the vicinity of the middle line, which itself maybe traced by a 
 streak. In the face, the lines are orbicular or radiating in various 
 directions. 
 
 An explanation of these distributions which do not seem to be 
 the result of accident, has taxed the ingenuity of observers. The 
 direction of the streaks has been referred to that of the nerves; to the 
 lines of Voigt, separating the nerve territories; to the lines of cleavage 
 of the skin; to the course of the bloodvessels; to the metameric 
 
CIRCUMSCRIBED KERATOSES 
 
 207 
 
 zones of Head; to the lines of fusion of the embryonic clefts; finally, 
 to stretching of cell-groups in the course of embryonic growth. 
 
 None of these theories explains all the arrangements which have 
 been noted; and the terms of nervous, zoniform, metameric, uni- 
 lateral, etc., nevi, are not justified. The same remark applies to the 
 term ichthyosis hystrix. 
 
 Fig. 
 
 -Linear hyperkeratotic nevi, very numerous, in a girl aged seven years. 
 Service of Dr. Variot. 
 
 The linear nevi, instead of being hyperkeratotic, may suggest 
 simple papilloma, psoriasis, or lichen; they may be hairy, pig- 
 mentary and so forth. 
 
 Not all linear dermatoses are necessarily nevi; in rare instances, 
 genuine cases of lichen planus, psoriasis, eczematides, prurigo 
 
208 KERATOSES 
 
 vulgaris, etc., are observed which assume a topography like the 
 linear nevi, appearing at any age and subsiding on appropriate 
 treatment. 
 
 Flat Senile Warts (Verruca Plana Senilis). — These keratotic ele- 
 vations, also known as seborrheal warts, have the following char- 
 acteristics: 
 
 They are rounded or oval, sometimes irregular, from the size of 
 a lentil to that of a green almond, more prominent in the center 
 than at the periphery, distinctly circumscribed, sometimes actually 
 overhanging, covered with an adherent horny and fatty layer, of 
 variable thickness, of a gray, brown or black color. After this coat 
 lias been removed by washing with soap, maceration, or rubbing 
 with ether, a mammillated, honeycomb or cauliflower-like sur- 
 face with furrows is exposed; the consistence is molluscoid or 
 granular. 
 
 Senile warts, generally numerous on the same individual, pre- 
 ferably occupy the flanks, the belt-line, the back, the chest, the 
 neck, the shoulders; many hundreds of them may be counted; they 
 are less frequently observed on the forehead, the temples and the 
 cheeks. They develop after the fortieth year of life, especially in 
 women; they may begin before the age of thirty. They persist and 
 multiply with the advance of years. 
 
 Histology shows either hypertrophy of the epidermis or atrophy 
 through invasion of the horny layer, but always some irregu- 
 larity; the papillae are deformed and twisted. Horny pearls are 
 often found in the interpapillary depressions. A special lesion, 
 described by Pollitzer, consists in a peculiar arrangement in whorls 
 of the Malpighian cells at certain parts. The hairs and glands are 
 atrophied; there is no true seborrhea. The subjacent cutis is often 
 in a state of senile degeneration, but presents no inflammatory 
 infiltration. 
 
 Their clinical features, their structure and their seat, everything 
 differentiates senile warts from the patches of senile keratosis with 
 which they are too often confused. They have not the same tendency 
 as the latter to undergo epitheliomatous transformation. 
 
 I consider them as delayed nevi, and they actually coincide 
 frequently with vascular nevi, fibroma molluscum, or pigmentary 
 spots. There is no connection as regards etiology and character 
 between senile warts and ordinary warts. 
 
 Treatment is instituted only on special request; mercurial oint- 
 ments, collodimn with salicylates or sublimate, black wash and even 
 strong caustic agents may be recommended. It is much more advis- 
 able, however, to resort to the galvanocautery cautiously handled 
 and combined if necessary with curettage; no perceptible cicatrix 
 must be produced. Radiotherapy seemed to me to be inefficient. 
 
CIRCUMSCRIBED KERATOSES 209 
 
 Electrolysis is very successful, but the method is much too laborious 
 in its application. [Destruction by means of carbonic acid snow may 
 be employed.] 
 
 Keratosis Senilis. — The usually multiple and scattered keratotic 
 spots which are observed especially on the face of aged individuals, 
 were formerly known under the names of "crasse des vieillards" 
 acne sebacee, etc. They seem to me to constitute a complication 
 of senile degeneration of the skin and frequently lead to multiple 
 epitheliomatosis (p. 685) ; from this viewpoint, they constitute an 
 obvious type of precancerous dermatosis. 
 
 A 
 
 B r 
 
 
 
 
 
 
 
 
 i 1 
 
 ; 
 
 
 
 
 
 D 
 
 ) 
 
 \\\.W/g 
 
 •i;. 
 
 
 \ \ ^ 
 
 -v---: - 
 
 -^ 
 
 -W 
 
 p^att 
 
 , 'Wr-' \ 
 
 
 
 
 
 Si 
 
 
 
 
 
 
 
 
 
 
 - " J * < i 
 
 -■:<<,:■'■ : \£S^ 
 
 
 
 
 
 
 '•=.' 
 
 Mr 
 
 i . '" 
 
 
 \ 
 
 
 1% ■ • 
 
 F 
 
 Sir 
 
 G 
 
 1 
 
 H 
 
 I, 
 
 . tiAfV** 
 
 Fig. 64. — Histology of senile keratosis. The section comprises the border of 
 a fairly extensive keratotic spot from the temporal region of an old man. A, 
 edema; B, epidermic globe; C, hyperkeratosis; D, sebaceous gland; E, elacin; F, hair 
 follicle; G, plasmatic infiltrate; H, elacin; I, plasmatic infiltrate. X 37. 
 
 The lesions of senile keratosis begin as dry yellowish or brownish 
 spots, or as warty elevations somewhat resembling seborrheal 
 warts, or again as irregular but fairly well outlined telangiectatic 
 red spots. Gradually they become covered with a gray or brownish 
 keratotic coat, friable or of dry consistence, with a wrinkled surface 
 which may bristle with irregular elevations. This very adherent 
 keratotic layer sends conical processes into the derma; its detach- 
 ment often gives rise to small hemorrhages; the changes become less 
 marked toward the borders of the spots; the skin in their center 
 may be atrophic or cicatricial. 
 14 
 
210 KERATOSES 
 
 Senile keratoses appear more or less soon after the fiftieth year in 
 very variable numbers, notably on the forehead, temples, nose, 
 cheeks, the back of the hands and wrists, sometimes on the neck 
 and the forearms. As a rule, they persist indefinitely and increase 
 in number, but they may disappear. 
 
 Their evolution into epithelioma is by no means necessarily fatal. 
 This is indicated by a transformation of the keratotic layer into a 
 crust, ulceration of the subjacent derma, at first superficial, and 
 the appearance of epitheliomatous pearls at the circumference. 
 
 Histology shows in the first stages an irregular hyperkeratotic 
 horny layer, provided with conical processes on its inferior sur- 
 face; a thinned mucous body, sometimes infiltrated with wander- 
 ing cells; an irregular and edematous papillary body. The corium 
 presents to a high degree the lesions of senile dystrophy, namely 
 the transformation of the elastic tissue into basophilic elacin, and 
 a colloid change of the connective-tissue strands; perivascular tracks 
 of cellular infiltration are seen, with a predominance of plasmocvtes 
 (Fig. 64). 
 
 The differential diagnosis must be made from the various nevi, 
 syphilides, psoriasis, rosacea, especially from lupus erythermatodes. 
 The patient's age and the location of the lesions are factors of 
 prime importance. 
 
 Treatment with salves and ointments containing keratolytic and 
 keratoplastic medicinal agents is often not particularly efficient. 
 Radiotherapy accomplishes frequently, though not invariably, a 
 complete disappearance without pain. The galvano-cautery, assisted 
 by curettage, yields excellent results. 
 
 In presenile dystrophy, in xeroderma pigmentosum, in radioder- 
 matitis, and in cutaneous arsenic poisoning, practically identical 
 keratoses in spots and warty elevations may occur; these dystro- 
 phies belong to the same natural group. 
 
 Gonococcal Keratoma. — A very rare variety of disseminated 
 keratosis has been described under the name of " blennorrhagic 
 keratoma" by Yidal, Jacquet, Jeanselme, Chauffard, and others. 
 Certain cases of gonorrhea, confined to bed on account of severe 
 arthropathies or myelopathies, present hard yellowish conical 
 elevations, comparable to drops of yellow wax or upholsterer's 
 tacks, scattered over the limbs and sometimes on the trunk. There 
 may be an erythematous border at the circumference. 
 
 Genuine carapaces of hyperkeratosis have been observed in the 
 palmar and plantar regions. These products disappear in two or 
 three months under simple attention to cleanliness. 
 
 Porokeratosis.— The porokeratosis of Mibelli (1893) and Respighi 
 is a rare affection, characterized by irregular circulate spots, the 
 area of which is atrophic, scaly or normal, with a papular border 
 
KERATODERMA 211 
 
 marked by a horny plate; this plate is imbedded in a "trench," or 
 groove from which it rises in the form of a prismatic crest. The 
 lesion begins with a horny cone wedged in a papule which slowly 
 spreads out. The lesions are situated especially on the extremities, 
 the face and the genitals; they have been observed in the buccal 
 mucosa. 
 
 Porakeratosis is often familial, but nothing more is known con- 
 cerning its etiology. Truffi associates it with the nevi. Mibelli 
 assumes a primary epidermal dystrophy of the glandular orifices, 
 more particularly of the sweat-pores. 
 
 The porokeratosis of Italian authors must not be confused with 
 the punctiform keratosis which will be briefly referred to in-the fol- 
 lowing and which the majority of writers also call porokeratosis. 
 
 KERATODERMA. 
 
 I employ the term keratoderma for the palmar and plantar 
 keratoses. 
 
 The skin of the palmar and plantar regions has a special structure. 
 It is predisposed to hyperkeratosis and in this case has a tendency to 
 crack, forming very painful fissures in the flexion folds. All dry 
 dermatoses in this locality assume an analogous appearance, which 
 renders the diagnosis rather difficult. 
 
 Some keratodermas are essential, representing malformations; 
 others are symptomatic, the result of repeated traumatisms, intoxi- 
 cations or localization of various dermatoses. 
 
 Essential Keratodermas. — Familial keratoderma, or Meleda disease 
 [keratoma palmare et plantare] is an ordinarily congenital, some- 
 times acquired affection, which frequently attacks several chil- 
 dren of the same family and has a marked tendency to hereditary 
 transmission. 
 
 The palmar aspect of the hands and fingers (Fig. 65), the plantar 
 aspect of the feet and toes, are symmetrically and as a whole, the 
 seat of a horny thickening. The borders are marked by a purplish 
 or bluish-pink edge from 4 to 5 mm. wide. 
 
 The hyperplastic horny layer may be smooth, soft, of a waxy 
 or brownish-yellow hue, made up of large very adherent lamellae. 
 In this case a local hyperidrosis is frequently noted which is regarded 
 by Lenglet as the initial phenomenon and the hyperkeratosis itself 
 is supposed to originate at the sweat orifices. I have sometimes 
 noted the presence of intracorneal bullae with turbid contents. 
 
 In other cases, the hyperkeratosis is dry, hard, roughened, of a 
 thickness which may reach a centimeter ; it is fissured in the folds, 
 or divided into polygonal blocks. 
 
 The underlying skin is invariably red, usually tense, sclerotic 
 
212 
 
 KERATOSES 
 
 and atrophic Tn well-marked forms, it is so much retracted at the 
 last phalanges that the fingers arc conical and tapering, as if enclosed 
 in a very tight-fitting, yellowish and horny case; the nails are 
 thinned and the nail bed is bloodless. 
 
 The movements of the hands and fingers are impeded and painful; 
 walking is difficult. 
 
 The lesions almost invariably encroach upon the anterior aspect 
 of the wri>t> and along the Achilles tendons; the knees, elbows and 
 articular folds may present thick, warty, aberrant patches, of a 
 brownish-red color, distinctly circumscribed, with dilated and 
 blackened pores. These patches may progress and extend, as 
 shown by casts preserved in the Museum of the St. Louis Hospital, 
 taken at intervals of ten years on the same patient. 
 
 Fig. 65. Hand of 
 
 ing girl, aged thirteen years, with congenital symmetric 
 palmar and plantar keratoderma. 
 
 Familial keratoderma is met with either isolated, or associated 
 with generalized ichthyosiform hyperkeratosis, of which itrepresents 
 merely a localized variety; in its course it resembles symmetrical 
 erythrokeratoderma with which it may coincide. 
 
 When essential keratoderma is not strictly congenital, it may 
 develop between the first months of life and the second year, or 
 even in late childhood. The onset is not easily discovered; it is 
 preceded by redness, hyperidrosis and exfoliation in hue lamellae. 
 
 The cases of delayed appearance are distinguished by several 
 authors under the name of symmetrical keratoderma of adults, 
 acrok'erai 'inn, or essential tylosis. The term of M61eda disease comes 
 from an island in the Adriatic, where Neumann and Killers found 
 this malformation to be endemic. In the non-hereditary cases, the 
 origin has been referred to consanguinity of the parents. 
 
KERATODERMA 213 
 
 Palmar hyperkeratosis is serious on account of its incurable 
 character and the resulting inconvenience, but the condition is 
 considerably relieved by moist or rubberized dressings and by kera- 
 tolytic agents. Radiotherapy, which constitutes the best treatment, 
 has led to noteworthy improvement, but to no complete cure in 
 my experience. 
 
 Symptomatic Keratodermas. — Occupational Keratoderma. — This 
 results from friction, pressure or various physical and chemical, 
 chronically repeated irritants, and represents a sort of diffuse callus. 
 The lesions are unilateral or symmetrical and their distribution is 
 often characteristic of certain occupations. 
 
 Fig. 66. — Arsenical keratosis. The illustration shows keratotic patches, similar 
 in type to others situated over the forearms, face, scrotum and legs, interspersed with 
 hyperpigmentations and several true epitheliomata. In addition, there occurred a 
 symmetrical keratoderma of the palms and soles. The disease was of twenty-five 
 years' duration and due to drinking water charged with arsenic. (Ormsby.) 
 
 Arsenical Keratosis. — Arsenical keratosis, a consequence of 
 chronic arsenic poisoning, is localized especially on the hands and 
 feet. It is often preceded by formication and attacks of desqua- 
 mative or bullous erythema. It persists indefinitely, even if the 
 arsenic medication is stopped. 
 
 It manifests itself under two forms which are sometimes asso- 
 ciated: (1) A diffuse yellowish scurfy thickening of the palmar and 
 plantar regions, with well-marked papillary crests; (2) verrucous 
 protuberances which occur in large numbers on both surfaces of 
 
214 
 
 KERATOSES 
 
 tli 
 
 the extremities, sometimes also the face and neck and which may 
 degenerate into arsenical cancer. 
 
 Eczema Keratoticum. — The most common kerato 
 referable to eczema and to syphilis. 
 
 Keratotic eczema or corneal eczema of Wilson 
 metrical and often of occupational origin. It may be partial or 
 extend over almost the entire region (Fig. 67) and is characterized 
 by its diffuse imperfectly marked borders which pass imperceptibly 
 
 nas are Those 
 
 is usually svm- 
 
 I'hnt.'ir kcfiiliitic cc/.cnm. 
 
 into the healthy skin. It has a tendency to spread along the large 
 grooves. The thickened horny layer splits and becomes exfoliated 
 in lamella 1 , exposing a reddened skin, where vesicles are rarely 
 observed. The histological lesions are those of eczema. Foci of 
 eczema or eczematides, are encountered elsewhere, especially on the 
 scalp. The duration of this affection is sometimes several years, 
 with remissions and relapses. It is treated with keratolytic agents 
 
KERATODERMA 
 
 21! 
 
 followed by reducing agents; radiotherapy is sometimes very 
 effective. 
 
 Palmar and Plantar Psoriasis. — Palmar and plantar psoriasis is 
 usually symmetrical and accompanied by a scattered eruption, but 
 it may be isolated, affecting only a single extremity. It consists 
 at the onset of hyperkeratotic yellowish spots which are distinctly 
 outlined and promptly become exfoliated in dry, friable lamellse 
 under which the bright red skin is seen. The spots which have 
 
 Fig. 68. — Genuine palmar psoriasis. 
 
 rounded and clearly outlined contours become confluent in poly- 
 cyclic patches (Fig. 68). The appearance may be extremely sug- 
 gestive of syphilis or trichophytosis, but it is rare for these spots 
 not to extend, as manifest patches of psoriasis, to the wrists or to the 
 dorsal regions of the hand, the fingers, or the feet, or for no other 
 spots to appear in different parts of the integument — which clinches 
 the diagnosis. Biopsy shows the characteristic lesions of psoriasis. 
 In this particular localization, psoriasis requires very energetic 
 treatment; sometimes it subsides spontaneously. 
 
21G KERATOSES 
 
 In pityriasis rubra pilaris, the palms and soles are diffusely red- 
 dened, dry, hyperkeratotic and thickened, but desquamation is 
 slight. 
 
 Lichen planus gives rise either to small, dry, horny papules, or to 
 depressed more or less confluent keratotic spots (Fig. 23), or to red 
 and finely scaly patches — or finally to total keratoderma. 
 
 Gonococcal Keratoderma. — Gonococcal keratoderma manifests 
 itself in the form of horny soles, sometimes a centimeter thick, or as 
 hyperkeratotic or crusted acuminate papules, surrounded by a dark 
 red halo; it affects the plantar and palmar regions, the back of the 
 feet, the lower limbs, sometimes the genitals and exceptionally 
 the upper limbs and the trunk. This affection, which is very 
 uncommon, has been observed especially in connection with gono- 
 coccal rheumatism. 
 
 Palmar and plantar trichophytosis, elucidated by the work of 
 Djellaleddin Moukhtar, is not, strictly speaking, a keratoderma, but 
 must be mentioned from the diagnostic viewpoint. It appears as 
 perfectly round or polycyclic red spots, surrounded by an epidermic 
 collar. Small vesicles may be discovered on their area and around 
 their circumference. The mycelium is abundantly present in the 
 vesicular fluid and in the scales. 
 
 Epidermophytosis of the same regions, more recently discovered, 
 is relatively frequent and presents a variety of aspects. It is there- 
 fore essential to keep in mind the imperative necessity of micro- 
 scopical examination in all more or less doubtful cases. 
 
 The reader is reminded that in the course of dysidrosis, or of the 
 pyodermatitides which are sometimes so obstinate in the palmar 
 and plantar regions (continuous- acrodermatitis), a clinical picture 
 suggestive of various keratodermas is sometimes seen. 
 
 The appearance of so-called punctiform keratosis (porokeratosis 
 of some writers), characterized by small, sometimes very hard, 
 scattered or grouped, miliary horny masses, may be produced, with 
 slightly variable modifications, by an entire series of skin affections : 
 lichen planus, follicular dyskeratosis, warts, keratotic nevi, familial 
 or arsenical keratoderma, etc. 
 
 The psoriatiform palmar and plantar syphilides, also erroneously 
 named syphilitic psoriasis by some authors, are the most important 
 of all the keratodermas. Bazin grouped nearly all the lesions 
 enumerated above under the heading of palmar arthritides, in order 
 to contrast them with syphilides in the same locality. 
 
 These syphilides are relatively common, they may appear at any 
 date between the third month following the infection and the most 
 remote tertiary stages. They resemble each other so closely that it 
 is not always possible to distinguish the premature from the late 
 forms; the latter are described by A. Fournier as "delayed secondary 
 
KERATODERMA 217 
 
 manifestations." Nevertheless, although certain pictures do not 
 indicate the age of the syphilitic infection, there are others belonging- 
 more particularly to one or other of its stages. 
 
 In the secondary stage, multiple lesions are especially met with, 
 consisting either of flat lenticular papules of a dusky red color, slightly 
 keratotic and scaly, or of depressed nummular spots, surrounded by 
 a keratotic ridge (Fig. 69) ; in the tertiary stage and in hereditary 
 syphilis tarda, round or polycyclic spots of a dark or coppery 
 
 H^^Hjiji^fj^gJnj^^^H 
 
 Fig. 69. — Early secondary palmar syphilide, contemporaneous with the roseola. 
 
 red, single or in small numbers, are more usually seen, which may 
 be markedly hyperkeratotic, or wrinkled and cracked, sometimes 
 bordered by tubercles (Fig. 70). 
 
 These various lesions are found on any part of the palmar surface 
 of the hand or fingers or the soles of the feet. Though not absolutely 
 diagnostic, a unilateral character of the lesion is somewhat more 
 frequent in tertiary and hereditary syphilis. 
 
 The diagnosis rests on the sharp limitation of the spots; on~ 
 their margin of hyperkeratosis with a central depression; on the 
 
21S 
 
 KERATOSES 
 
 infiltration of the base, which is of greai value when demonstrable; 
 finally, on the slight tendency of the lesions to encroach upon 
 the neighboring regions. It goes without saying that the ante- 
 cedents, the co-existence of other symptoms of syphilis, and the 
 Wassermann reaction must be taken into consideration. 
 
 i it. Late palmar syphilide. 
 
 These syphilides are often obstinate and recurrent. Treatment 
 with calomel injections, or preferably arsphenamin, often accom- 
 plishes their rapid removal, while all other less forcible measures 
 generally fail. Local treatment, with mercurial or with salicylic 
 acid plaster may serve as a useful adjuvant. 
 
 Moreover, in all keratodermas, one must never neglect to soften 
 and remove the horny layer (by means of moist dressings, inunction 
 with potash soap, or salicylic acid preparations), in order to open 
 the way for or otherwise assist the special medication that is 
 indicated. 
 
 KERATOSIS OF MUCOUS MEMBRANES. 
 
 The mucosa of the buccal cavity and the genital organs possess, 
 like the skin, a papillary body and a Malpighian layer, but the 
 
Keratosis of mucous membranes 219 
 
 granular layer is absent in the latter and the keratinization of the 
 superficial layers is incomplete. 
 
 The lining of the red border of the lips, that of the prepuce and 
 glans, as well as that of a large portion of the vulva, has a structure 
 related to that of the epidermis, so that these surfaces are called 
 semi-mucosse. 
 
 Under pathological conditions, these mucosae and semi-mucosse 
 may become the seat of white spots or patches due to the appear- 
 ance in their epithelium of a great abundance of keratohyalin and 
 eleidin and a genuine keratinization. The term of keratosis is justi- 
 fied in these cases. 
 
 Leukoplakia. — This affection, which is also known as leukokera- 
 tosis, white spots of smokers — and erroneously called buccal 
 psoriasis, tylosis lingua, buccal ichthyosis, etc. — is the most common 
 form of keratosis of mucous membranes. 
 
 Symptoms. — Leukoplakia is almost invariably located in the mouth, 
 exceptionally in the genital regions. In the mouth, it is usually the 
 tongue, on its anterior half, which is involved to the highest degree. 
 In some cases, the lesions predominate on the lateral portions of the 
 back of the tongue, in others on the margins or the middle; or again, 
 the upper surface of the organ is affected as a whole; the lower 
 surface is less commonly invaded. 
 
 More frequent, but as a rule not so marked, is a localization of 
 the disease on the internal aspect of the cheeks, in the form of a 
 symmetrically arranged triangle; representing the commissural 
 white spots of smokers. The posterior region of the cheeks, the 
 gums and the palate, are not often attacked by leukoplakia, which 
 is altogether exceptional in the pharynx and larynx. 
 
 On the lips, leukoplakia occupies the posterior surface, the free 
 margin, the external red surface, sometimes the commissures, or all 
 these regions as a whole. 
 
 In women, leukoplakia may be observed on the vulva, notably 
 on the inner surface of the labia majora, on the labia minora, the 
 prepuce, the clitoris, the vestibule, sometimes in the vagina and 
 around the anus. In men, leukoplakia of the prepuce and glans 
 is rather rare. 
 
 The lesions begin with a smooth condition of the mucosa, which 
 is reddened or of an opaline hue. Once established, they assume 
 two different aspects, according to the severity of the case. 
 
 Mild leukoplakia is characterized by obliteration of the papillae 
 and the grooves of the mucosa, which shows a whitish, grayish, 
 bluish or white color, indicative of a change in the transparency of 
 the epithelium. Exceptionally large pinkish papillae may be seen 
 shining through this smooth whitish veneer. 
 
 The lesions are arranged in spots or patches of extremely variable 
 
220 KERATOSES 
 
 dimensions, irregular configuration, sinuous, festooned or ragged 
 margins, sometimes sharply outlined, sometimes gradually fading 
 into the normal state. The entire leukoplasic surface may present a 
 uniform appearance or the center may be more opaque and thick- 
 ened. The confluence of these spots gives rise to patches, unevenly 
 checkered in dark red, gray or white. The keratotic layer, which 
 is always very adherent, cannot be removed by scraping, without 
 exposing the submucosa; but it is apt to desquamate in small opaline 
 shreds, which on the lips, for instance, the patient can pull off with 
 his teeth. 
 
 The severe or marked form of leukoplakia is connected by inter- 
 mediate stages with the mild type. The thickening of the mucosa 
 and of its horny coat may become considerable. Either on an 
 already leukoplasic surface, or on a healthy basis, hard, inelastic, 
 pearly or snow-white patches make their appearance, several centi- 
 meters thick with gently sloping or steep borders, with a smooth or 
 roughened surface, closely adherent to the underlying tissues. They 
 may become detached spontaneously, at intervals of months or 
 years, but are promptly reproduced. The entire tongue is sometimes 
 held in a cracked "cardboard" leukoplasic case. The cheeks, the 
 vulva, or the glans penis may also be covered with a coat of this kind. 
 
 The keratotic patches are often furrowed by folds or fissures; 
 more rarely, they are studded with acuminated horny protuberances. 
 This verrucous variety is especially noteworthy as being frequently 
 the prelude to epitheliomatous changes. 
 
 Another complication of leukoplakia, inconvenient and trouble- 
 some rather than actually serious, is an obstinate ulceration which 
 I have named leukoplasic ulcer and which will be discussed else- 
 where in this book (p. 307). 
 
 The condition of the mucosa underlying the leukoplakia is difficult 
 to determine. In the case of the tongue, it is as a rule sclerotic and 
 even retracted proportionately to the hyperkeratosis, either super- 
 ficially or deeply, as a result of the syphilitic sclerotic glossitis which 
 i^ the ordinary substratum of the severe leukoplakias. Elsewhere 
 it is often in a more or less marked state of atrophic sclerosis. 
 
 The subjective sensations — which are absent in the mild forms of 
 the disease — consist of an impairment of mobility and an unpleas- 
 ant sensation of dryness and hardness in the severe cases; acute 
 tenderness and shooting pains usually appears only as the result of 
 fissures. 
 
 Vulvar Leukoplakia carefully studied by Jayle and Bender — 
 does not differ from the same disease as seen in the mouth. It may 
 affect the vaginal mucosa and very rarely the uterine cervix. It 
 may precede or accompany kraurosis or sclerotic atrophy of the 
 vulva, with which it has been confused. 
 
KERATOSIS OF MUCOUS MEMBRANES 221 
 
 The course of leukoplakia is altogether irregular. It usually pro- 
 gresses slowly and persists throughout life. It may remain entirely 
 stationary under the influence of proper hygiene, or it may even 
 subside and disappear, at least partially; but it is very prone to 
 recurrence. 
 
 Leukoplakia and Cancer. — The gravity of leukoplakia is due to its 
 complications, which are frequent and very dangerous. Fissures, 
 cracks and erosions are very common in the vicinity of carious 
 teeth or as the result of faulty hygiene; they give rise to acute radia- 
 ting pains and may lead to lymphangitis or to suppuration. 
 
 Fig. 71. — Cancer (lobulated epithelioma) on leukoplakia of the tongue. 
 
 Epithelioma, however, constitutes the real danger of leukoplakia. 
 It may supervene in all the forms, especially the most severe types, 
 and at any stage of the leukoplakia. Its relative frequency has been 
 variably estimated at 30 and even above 50 per cent, of the cases; 
 a ratio of 15 to 20 per cent, seems to me nearer the truth. [This 
 estimate which seems to me very high applies, of course, only to 
 the severe cases.] The physician may save his patient from an 
 awful death, such as supervenes in cancer of the tongue, if he 
 manages to discover in time the incipient complication and is 
 sufficiently energetic and convincing to obtain consent to a timely 
 operation. 
 
222 KERATOSES 
 
 Cancer of the tongue on a basis of leukoplakia (Fig. 71) is almost 
 invariably of the lobulated or spinocellulare type and of the variety 
 which I call cancroid: exceptionally, it is of the tubular type. It 
 has two principal modes of onset. 
 
 In most cases it begins with a circumscribed, lenticular or more 
 extensive papillomatous elevation, often encircled by a keratotic 
 margin, with a very slightly indurated base; under this superficial 
 form it spreads on the surface during a few weeks, a month or two, 
 before invading the depths of the tissues, so that prompt operative 
 interference is not infrequently successful. 
 
 More rarely the epithelioma develops deeply from the start, 
 originating from a fissure which has persisted one or two weeks and 
 at whose level palpation reveals a minute circumscribed woody 
 induration. In these cases, surgical intervention can hardly come in 
 time. Leukoplasic ulcers only exceptionally give rise to cancer. 
 
 On the lips, cheeks and genitals, epithelioma appears under 
 entirely similar conditions. 
 
 I have emphasized for many years the line of conduct to be fol- 
 lowed when cancer is suspected in the course of a leukoplakia; and 
 increasing experience causes me to be more and more positive in this 
 respect. 
 
 What should not be done, is: ( 1 ) to wait until the symptoms become 
 more pronounced, the epithelioma develops and the glands become 
 enlarged; (2) to resort to an antisyphilitic "therapeutic test" which 
 causes the loss of valuable time; (3) to irritate the suspicious lesion 
 with cauterization of any kind, diathermia, etc.; (4) finally, to try 
 radiotherapy or radium, which are inefficient or even harmful in 
 these cases. 
 
 What .should be done: in all cases where the diagnosis is not abso- 
 lutely certain, a specimen removed from the living subject should 
 be at once examined under the microscope, a step which will provide 
 a definite answer in less than twenty-four hours; or, when cancer is 
 known to exist, to proceed at once and without delay to the surgical 
 extirpation of the lesion, which affords the only prospect of salvation. 
 [The rich lymphatic tissue of the tongue increases the risk of dis- 
 semination as a consequence of the manipulations inseparable from 
 biopsy. After biopsy, therefore, a delay of even twenty-four hours 
 may have serious consequences. In my opinion, the complete 
 operation, whenever possible, should follow immediately on the estab- 
 lishment of the diagnosis which should therefore be made on frozen 
 sections, with due consideration of the difficulties of this method.] 
 
 Pathological Anatomy. On a leukoplasic mucosa ( Fig. 72) the rete 
 Malpighii is greatly thickened (acanthosis) and its interpapillary 
 plugs are hypertrophied in all directions; between the mucous body 
 and the extremely thick horny layer which covers it, and which 
 
KERATOSIS OF MUCOUS MEMBRANES 223 
 
 consists of cells deprived of their nuclei, a granular layer has made 
 its appearance, with very abundant keratohyaline and eleidin, 
 diffusing into the stratum corneum; these lesions explain the white- 
 ness of the patches. 
 
 In the papillary body of the corium is seen a variable infiltration of 
 round cells around the vessels, as well as sometimes the lesions of 
 endo-peri vasculitis and connective-tissue sclerosis. 
 
 B 
 
 1 
 
 c 
 
 A ' 
 
 i 
 
 I . ,.■+ / 1 j . \\ 
 
 
 ^«^-, 3 :/. /■'•' ■ w "'V-;--. v ^.^- v .-=: ■'"' ^ \J \ / 
 
 
 • / . . ■:. ;. mm 
 
 : ' i : .; : 
 
 
 Fig. 72. — Simple and verrucous leukoplakia of the tongue. Under the epithe- 
 lium, which is greatly thickened and abundantly provided with keratohyalin and 
 diffuse eleidin, is seen an inflammatory cellular infiltrate, especially abundant at 
 the level of the verrucous portion; a newly formed layer of sclerotic tissue, traversed 
 by numerous dilated bloodvessels, has become interposed between the epithelium and 
 the muscular tissue. No trace of epitheliomatous change is demonstrable. A, simple 
 leukoplakia; B, eleidin; C, verrucous leukoplakia; D, muscular tissue; E, sclerosis; 
 F, inflammation. X 18. 
 
 When epitheliomatous transformation occurs, it results from 
 atypical budding of the interpapillary processes or of the epithelium 
 which lines the fissures (Fig. 192). Invasion of the lymph spaces 
 takes place very rapidly, especially in the tongue. 
 
 Etiology. — Leukoplakia is at least ten times more frequent in 
 men than in women. It is observed especially from thirty to fifty 
 years of age, but cases have been reported at the age of twelve years 
 (Benard) or even younger. I have encountered it, complicated by 
 cancer of the tongue, in a girl of nineteen years, which is excep- 
 
224 KERATOSES 
 
 tional from every point of view. Leukoplakia may result from multi- 
 ple causes of different kinds. The equation: 
 
 Leukoplakia = syphilis + tobacco 
 
 although often true, is certainly too absolute. Tobacco is the most 
 powerful of the local causes; but dental lesions, false teeth, abuse 
 of alcohol and condiments, etc., also play a part in the production 
 of buccal leukoplakia, especially in non-smokers and in women. 
 Other irritants intervene in genital and anal leukoplakia. 
 
 In the great majority of the cases, leukoplakia develops on a 
 syphilitic soil, but I believe that, even on the plea of hereditary 
 syphilis, it is not justified to consider it as an invariably para- 
 syphilitic affection, as maintained by Professors Landouzy and 
 Gaucher. There are cases where syphilis is absent, where the 
 Wassermann reaction is negative and where nothing can be sus- 
 pected except local irritative factors, obscure auto-intoxications, or 
 perhaps an individual predisposition. 
 
 At the present state of our knowledge it is impossible to say if 
 it is correct to recognize a syphilitic leukoplakia, and other nicotine, 
 dental, post-infectious leukoplakias, differing by their symptoms 
 and their course, or if leukoplakia is a syndrome resulting from 
 various causes, a modification of the epithelial evolution resulting 
 from infectious or toxic vascular lesions. The last-named theory 
 is the most probable in my opinion. 
 
 Treatment. — This must be carefully handled and requires in the 
 first place a strict buccal hygiene: absolute abstinence especially 
 from tobacco, from alcohol, condiments and highly spiced foods, 
 irritative mouth-washes; the teeth must be put and kept in perfect 
 condition. 
 
 Soothing or weakly alkaline irrigations of the mouth with Vichy 
 water, or Saint Christau water, are useful palliatives, preferable to 
 pastils and compressed tablets. The warm mineral springs of 
 Sainl Christau, with local spraying, or to a less degree, various 
 sulphur springs, yield favorable results. 
 
 Among topical applications, those most to be recommended are 
 glycerol salves or ointments made with balsam of Peru, oil of cade, 
 oil of birch, or salicylic acid. In case of thick keratotic patches, 
 their detachment may be furthered by painting with acid nitrate of 
 mercury, chromic acid, or potassium bichromate, etc. Sometimes, 
 the destruction of certain patches with the thermocautery, or their 
 surgical removal, may be called for. In a general way, however, 
 caustics arc not /<> he trusted, especially in case of fissures, which 
 patients like to treat and abuse with silver nitrate; cauterizations 
 are certainly more injurious than useful. Radiotherapy and radium, 
 
KERATOSIS OF MUCOUS MEMBRANES 225 
 
 energetically employed, have a few cures to their credit, but on the 
 other hand a large number of failures are on record. 
 
 The operative indications in case of probable or certain cancer 
 need not be repeated here. 
 
 General treatment with antisyphilitic agents, is evidently required 
 in the presence of specific antecedents or a positive Wassermann 
 reaction; but it has been found effective even in cases where 
 syphilis was apparently excluded. Intragluteal calomel injections 
 exert such a preponderating action in leukoplakia that they were 
 accorded the preference until the introduction of arsenobenzol ; 
 the latter is still more active, especially in combination with 
 soluble mercurial injections. In obstinate cases, I have often 
 been excellently served by local treatment with injections of very 
 dilute cyanide of mercury. Iodides are not to be recommended. 
 When an established leukoplakia in a syphilitic patient has only 
 partially yielded to specific treatment, or resisted it, the advantage 
 will at least have been served of opposing the extension of the dis- 
 ease and preventing the appearance of other syphilitic manifestations. 
 
 General hygienic recommendations must not be neglected, 
 especially in regard to diet, correcting dyspepsia if necessary, or 
 controlling any auto-intoxications which may have been discovered. 
 
 There is a certain class of leukoplasic patients whose life is made 
 miserable by a regular "cancerophobia," liable to be maintained 
 by treatment of any kind. In these cases, a judicious psychotherapy 
 is indicated. 
 
 Syphilitic Glossitis. — It seems to me useful to describe in connec- 
 tion with leukoplakia the lesions which secondary and tertiary 
 syphilis so frequently produce upon the tongue. This organ may 
 present : 
 
 1. The smooth patches of Fournier; "mowed-lawn patches" of 
 Cornil. These are pinkish spots, devoid of papillse, dry, non-indur- 
 ated, round or oval, distinctly outlined, though without special 
 border. These lesions may be premature, developing rather rapidly, 
 or delayed, and in this case are much more obstinate. 
 
 2. Opaline mucous patches seen only on the margins or at the tip 
 of the tongue, generally near carious teeth; sometimes they are 
 eroded or fissured; rarely, on the back of the tongue, they are 
 papular or lozenge-shaped. 
 
 3. Hypertrophic or papillomatous papules, with a gray or reddish 
 surface, very rare, occupying the vicinity of the circumvallate 
 papilla? where they become confluent in a large patch; from here 
 they reach the back of the tongue, which then assumes the appear- 
 ance called "toads' back." 
 
 4. Tuber culo-ulcerative syphilides and gummas, which will be dis- 
 cussed elsewhere; these may leave sclerotic cicatrices. 
 
 15 
 
22ii 
 
 KERATOSES 
 
 5. Finally, sch n tic glossitis, of the tertiary period, very common, 
 especially in men; it may be superficial or deep. 
 
 In the superficial form there are a few islands of cortical sclerosis, 
 or a single smooth red surface, with lamellar induration, sometimes 
 complicated by fissures. 
 
 Dei "p glossitis, occupying especially the middle or the borders of 
 the tongue, or its entire anterior half, is characterized by an 
 irregular lobulation, prominent papillae being separated by deep 
 grooves united in a network: fibrous induration of the organ is also 
 demonstrable Fig. 73). 'Die mucosa is wine-red in some places, 
 discolored in other-, smooth, tense, practically devoid of papilla? 
 throughout. 
 
 Fig. 7'.',. — Sclerot 
 
 ijred 
 
 ssitis of the deep variety, in a woman 
 ixty years. 
 
 The coexistence of syphilitic lingual sclerosis and leukoplakia is 
 very common. 
 
 Sulcated or Scrotal Tongue. Sclerotic glossitis must not be con- 
 fused with ;t congenital, often familial, malformation which bears 
 this name. The organ in such cases is lobulated and fissured; its 
 very villous surface is studded with prominent fungiform papillae. 
 But its consistence is soft, there is no pain and the condition is 
 absolutely permanent. 
 
 Median Rhomboidal Glossitis. -This affection was described in 
 January of 1914 by Brocq and Pautrier; it is not rare and I have 
 seen numerous instances. The dorsal asped of the tongue, in front 
 
KERATOSIS OF MUCOUS MEMBRANES 227 
 
 of the circum vallate papillae presents a reddish raw surface; the 
 lesion is usually mammillated, slightly indurated, indolent, and 
 extremely persistent. Anatomically, nothing is found but hyper- 
 acanthosis and a moderate infiltration of the corium. This glossitis, 
 which occurs especially in adults, is often wrongfully ascribed to 
 syphilis; its nature is unknown; it resists all local or general treat- 
 ment. 
 
 Lichen Planus of Mucous Membranes. — This is very commonly 
 confused with leukoplakia or with syphilides. Its diagnosis never- 
 theless is relatively easy. 
 
 Lichen planus of the^mucosse, especially of the mouth, is not rare. 
 It is observed in about one-half of all lichen cases. It may persist 
 beyond the cure of the cutaneous manifestations, or it may consti- 
 tute a primary and sometimes exclusive localization. Familiarity 
 with its characteristics is therefore necessary. 
 
 Fig. 74. — Lichen planus of the tongue in a man aged forty-two years. 
 
 The seat of election of lichen planus of the mucosae is in the first 
 place on the internal aspect of the cheeks, at the level of the alveolar 
 margin, preferably opposite the last molars. It manifests itself on 
 one side, or symmetrically, in form of one or several white patches 
 with an irregular reticular or annular arrangement resembling lace- 
 work, pure white or bluish in color, on a normal background; the 
 more or less delicate network is crossed by larger bars. Erosion 
 or desquamation never occurs. 
 
 Next in order is the localization on the tongue (Fig. 74), which 
 may present either patches of a dull bluish white, smaller than a 
 lentil, with a reticular or fern-leaf design, or opaline surfaces 
 through which a few rose colored papillae project. 
 
228 KERATOSES 
 
 Lichen planus may furthermore be met with on the lips, palate, 
 
 gums, tonsils, on the glans and prepuce, where it is often annular, etc. 
 
 These lesions are absolutely sluggish and indolent; they persist 
 
 for months, or oftener for many years, undergoing very gradual 
 
 changes. 
 
 Histology shows a thickening of the epidermis in all its layers, 
 the appearance of a stratum granulosum, dome-shaped papilhe, 
 and a cellular infiltration in the papillary body. The structure is 
 accordingly entirely that of lichen planus of the skin. The explana- 
 tion of the white color i> the same as for the network of the cutaneous 
 papules of typical lichen planus; it moreover assumes an identical 
 form in the majority of cases. 
 
 The treatment of lichen of the mucosae need not be very active, 
 the condition being obstinate but by no means serious. It never 
 leads to cancer. Soothing mouth washes, inunction with balsam of 
 Peru, painting with potassium permanganate, 1 to 100, are quite 
 sufficient. High frequency currents and radium therapy have not 
 yielded favorable results in my experience. A bland diet, good 
 hygiene, a quiet life, arsenic internally, are recommended. 
 
 Lupus Erythematodes. — It is exceptional for lupus erythematodes 
 to affect the mucous membranes. It is sometimes seen to radiate 
 in the form of a scaly redness on the posterior aspect of the lower 
 lip starting from the free border. When it develops on the internal 
 aspect of the cheeks or on the tongue, it manifests itself in the form 
 of a circumscribed patch, mottled with white and bright red, and 
 partly atrophic. 
 
 Smooth Patches of the Tongue.— Occasionally, the tongue is seen 
 to present >pot> or large patches devoid of papilhe, reddish and 
 glistening, without a white margin, absolutely stationary during 
 months or years. They are entirely indolent and the patient may 
 be unaware of their existence. In other cases, they are very sensitive, 
 and associated with ghssodyniu. 
 
 These patches arc always suggestive of the cropped patches of 
 sj philis, or of incipient leukoplakia. I am personally convinced that 
 they may be referable to a variety of causes, notably tuberculosis, 
 diabetes, chronic dyspepsias, severe neuropathies; sometimes they 
 are connected with carious teeth or badly fitting artificial dentures. 
 Those cases in which desquamation and a varnished appearance 
 are extensively combined, or involve almost the entire tongue, are 
 known under the name of red tongue, or glossitis of nervous arthritics. 
 Glossitis Exfoliativa Marginata. — This peculiar affection which 
 also bears the names of exfoliatio areata, or geographical tongue, 
 gives rise to circinate patches, rings and other designs upon the 
 tongue. The spots are composed of a white border, one or two 
 millimeters wide, within which lies a desquamated surface, bright 
 
KERATOSIS OF MUCOUS MEMBRANES 229 
 
 red near the margin, gradually fading away at a distance from it. 
 More or less rounded at first, the spots spread rapidly and become 
 confluent with their neighbors ; the resulting design may thus become 
 entirely altered in a day or two. New spots are incessantly repro- 
 duced. There is no induration of the mucosa. 
 
 Entirely indolent, usually ignored by the bearer, this affection 
 lasts for years or indefinitely. Its etiology is unknown. It is 
 observed in children and in adults. It is often familial. Sulcated 
 tongues are specially predisposed to it. In spite of the parasitical 
 appearance of the lesions, no case of contagion has been reported. 
 Confusion must be guarded against, especially with syphilitic lesions. 
 Parrot referred exfoliative glossitis to congenital syphilis, which is 
 certainly incorrect. 
 
 [Chronic superficial excoriation of the tongue, or Mceller's glossitis, 
 is characterized by irregular circumscribed intensely red spots of 
 great chronicity, without tendency to extension or ulceration, located 
 in the middle or the anterior portion of the tongue. Contact with 
 food usually provokes severe burning or lancinating pain.] 
 
 Black (Villous) Tongue. — This is a lingual keratosis, in which the 
 filiform papillae, far from becoming obliterated, as in leukoplakia, be- 
 came immediately elongated and assume a dark, black or brown color. 
 
 The affection begins on the middle line, not far from the circum- 
 vallate papillae and spreads forward and to the sides, remaining 
 more pronounced at its point of origin; the borders of the lesion are 
 diffuse. The papillae, which may reach the length of a centimeter, 
 lie like mown wheat and a parting may be made as in the hair 
 (black hairy tongue). The brown color is darker at the extremity of 
 the papillae. 
 
 When these papillae are excised, the microscope shows an enor- 
 mous hypertrophy of their corneal sheath, the lamellae of which 
 adhere to the axis and spread away from it like the branches of an 
 old pine tree. The presence of eleidin has been reported at the 
 border of the rete. The black color is due, not to foreign bodies 
 or to pigment, but to a smoky tinge of the horny substance itself, 
 as in black ichthyosis. 
 
 This rather uncommon affection is observed in adults and aged 
 individuals; I have seen it associated with pharyngo-mycosis . It 
 proceeds in attacks, followed by partial desquamations; it is 
 sometimes prolonged for months or years and has a tendency to 
 recurrence. 
 
 Black tongue is neither contagious nor inoculable. It has been 
 suspected of being due to a special infection by a microbe or a yeast. 
 But the results of investigations which have been undertaken to 
 prove this are entirely contradictory and the parasitical theory can 
 no longer be maintained (Lebar, 1917). 
 
230 
 
 KERATOSES 
 
 There arc cases of villous tongue, presenting identical features, 
 but without a brown or black coloration. 
 
 This affection must not be confused with a simple coated tongue, 
 with an accidental discoloration due to articles of food or medicinal 
 agents, with the pigmentation of Addison's disease or that of 
 argyria. Mouth washes with peroxide water sometimes produce 
 at the end of a certain time an appearance identical with that of 
 villous black tongue; but the surface promptly returns to the normal 
 when these washes are omitted. In several great dystrophies, such 
 as acanthosis nigricans and psorospermosis, the tongue is villous 
 in its entire extent, but of a normal or whitish hue. 
 
 The treatment consists of alkaline mouth washes and painting with 
 a 5 per cent, or 10 per cent, alcoholic solution of salicylic acid. 
 
 DYSKERATOSES. 
 
 The dermatoses which I group under this heading are charac- 
 terized by a faulty development of the epidermis, in the course of 
 which a certain number of Malpighian cells become differentiated 
 from their fellows, undergoing an abnormal, premature and imper- 
 fect keratinization. These dyskeratotic cells are present in the 
 layers of the epidermis, as far as in the horny layer, in the form of 
 
 FlG. 75. — Round bodies and granules of follicular psorospermosis. a and h 
 round bodies, Malpighian cells surrounded by a membrane and containing granula- 
 tions of keratohyalin and a nucleus; c and d, granules, nucleated dyskeratotic cells 
 which have completed their development. 
 
 "round bodies," "granules" (Fig. 75), globes or corpuscles, with 
 or without nuclei, easily distinguished from the still normal cells as 
 well as from the parakeratotic cells. 
 
 The group of dyskeratoses comprises: (1) The disease which I 
 had named psorospermosis follicularis vegetans; (2) Paget's disease 
 of the nipple; (3) the precancerous dermatosis of Bowen, or lenticular 
 and disco id a I dyskeratosis. 
 
 From the strict viewpoint of the histological structure, moUuscum 
 contagiosum should likewise be classified with the dyskeratoses; 
 
DYSKERATOSES 231 
 
 but this affection is altogether different from the preceding and 
 will be discussed with the benign tumors. 
 
 Dyskeratosis and analogous cellular changes are also observed 
 in several forms of cancer, notably in the majority of spinocellular 
 epitheliomas, where they were formerly described under the name 
 of physalides (Virchow) and more recently under that of pseudo- 
 coccidias; and two dyskeratoses, Paget's disease and Bowen's, take 
 first rank among the precancerous affections. This fact is interest- 
 ing and suggestive, but its significance is not clear as long as the 
 cause and nature of dyskeratosis remain unknown. 
 
 Darier's Disease. — This important dermatosis which I described 
 in 1889 under the name of psorospermosis follicular is vegetans, is gen- 
 erally called Darier's disease, especially abroad; the most appropriate 
 denomination for it, in my opinion, would be dyskeratosis follicularis. 1 
 
 It manifests itself clinically as papulo-crusts, often follicular, 
 capable of becoming confluent in verrucous surfaces with crumbly 
 margins, located symmetrically in certain definite regions. It is 
 essentially chronic and almost incurable. 
 
 The improper name of psorospermosis which I had attributed to 
 it, was based on an erroneous interpretation of the corpuscles which 
 are found in the epidermis and which at the time were mistaken 
 for coccidia or psorospermia, namely for parasites of the sporozoa 
 group. They have now been shown to be really dyskeratotic epi- 
 dermic cells. 
 
 The etiology of this dermatosis is unknown, it has been observed 
 in all countries, but is relatively rare; it seems to affect the 
 male sex somewhat more frequently; its familial and hereditary 
 character is apparent from numerous observations, but there is 
 nothing to indicate contagiousness. It has been compared with 
 ichthyosis, the icthyosiform hyperkeratoses and acanthosis nigricans; 
 there is a tendency to regard it as a dystrophy of the epidermis of 
 congenital origin. 
 
 The typical eruptive lesion is a papule covered with a grayish 
 brown crust, having the dimensions of a pin-head to a small lentil. 
 On removal of the hard and horny, prominent or flattened, rather 
 adherent crust, it is found to be imbedded in a funnel-shaped de- 
 pression with raised margins, into which it sends a soft yellowish 
 process, of sebaceous appearance; this depression is the dilated 
 orifice of a pilo-sebaceous follicle. There are other lesions, however, 
 which are not follicular. 
 
 At the onset the patients notice a dirty tinge and roughened 
 state of the skin; later on, the crusts become confluent in warty 
 patches. 
 
 1 In the original this section is headed Psorospermosis, etc. The editor has 
 substituted the name by which the disease is generally known. — S. P. 
 
232 
 
 KERATOSES 
 
 In the groins, the axilla' and in all moist regions, pinkish globular 
 or crater-shaped vegetations may develop, in exceptional cases, 
 arranged in cauliflower or fungoid masses, having an offensive odor. 
 
 The eruption is symmetrical and occupies large areas. Its sites 
 of election are: the face, especially the temples and the naso-labial 
 
 -Follicular dyskeratosis [Darier's disease]; gene 
 dermatosis. 
 
 distribution of the 
 
 fold; the scalp, which becomes crusted and moth-eaten, but without 
 alopecia; the concha? of the ears, the presternal and interscapular 
 grooves; the belt line, the perigenital region and the large articular 
 folds. This topographical distribution is in the main that of 
 seborrhea (Fig. 76); tlie entire trunk and the external aspect of the 
 
DYSKERATOSES 
 
 233 
 
 limbs may be likewise involved. So-called abortive or incomplete 
 cases are not very uncommon. 
 
 On the back of the hands, elevations identical with flat warts are 
 often seen; the palmar and plantar regions present a punctate 
 keratosis composed of yellowish translucid points; the nails are 
 striated and brittle; the tongue may be villous. 
 
 The disease begins, in one-half of the cases, between eight and 
 sixteen years of age (Fig. 77), but also earlier or later; sometimes 
 at the temples and face, sometimes in the groins; it spreads rapidly 
 and then remains indefinitely stationary. It is accompanied by no 
 subjective symptoms and interferes in no way with the general 
 health. 
 
 Fig. 77. — Follicular dyskeratosis [Darier's disease] in a girl aged eleven years. 
 
 The pathological anatomy is characteristic. The illustration 
 (Fig. 78) conveys a sufficient idea of the condition. 
 
 The microscopical demonstration of the granules in the crusts 
 which are easily removed from the patient, and of the round bodies 
 in the underlying substance, is very easy and suffices for a positive 
 confirmation of the clinical diagnosis. 
 
2:51 KERATOSES 
 
 Without curing the psorospermosis entirely, it is possible to 
 improve the patient's condition very markedly by baths and soap 
 washes, inunctions with salves containing keratolyses, followed by 
 reducing agents as well as by means of radiotherapy. 
 
 Paget's Disease of the Nipple. -This is a chronic affection which 
 develops on the nipple and areola of women past forty years of age; 
 or, exceptionally in men in the perineoscrotal and some other regions. 
 It seemes to be less uncommon in England and in the United States 
 than in France. 
 
 
 /* 
 
 
 . ■' V:- 
 
 
 ; 
 
 . j** 
 
 6 
 
 Fig. 78. — Histology of follicular dyskeratosis; section through a perifollicular 
 papulo-cmst. a, orifice of a hair-follicle ; b, b, hairs, and c, sebaceous gland, unchanged; 
 d, thickened horny layer containing (in e e) collections of granules; /, /, granular 
 layer interrupted at the level of the foci of dyskeratosis; g, g, fissures and lacunae, 
 resulting from fibrino-nmcous disintegration of the epidermis, in which a few granules 
 are seen Boating {h, h); i, i, round bodies. 
 
 At the onset, only a few small crusts are seen on the nipple, 
 with warty elevations and sometimes a serous oozing. After some 
 months or years, a progressively extensive erosion makes its ap- 
 pearance and may invade the entire integument of the breast. At 
 its fully developed stage, there exists an eroded or ulcerated red 
 patch, mottled with pinkish epidermis-covered islands, remarkable 
 for its distinctly outlined polycyclic contours, which are bordered 
 by a narrow margin or cuff of scales (Fig. 79). The eroded surface 
 
DYSKERATOSES 235 
 
 presents a very distinct parchment-like induration; it never under- 
 goes retrogression or spontaneous cure. The nipple is retracted. 
 The lymph glands are not usually enlarged. Finally, sometimes 
 after a considerable number of years, a malignant neoplasm may 
 supervene in the form of a hard superficial or deep node which ulcer- 
 ates and presents the usual appearance of cancer of the lactiferous 
 ducts, or of ordinary cancer of the breast. 
 
 The differential diag?wsis from eczema of the mammary areola, 
 which is practically limited to the puerperium or to cases of scabies 
 (Fig. 157), has less distinctly circumscribed borders and takes an 
 acute course, is easy. Certain superficial epitheliomas, which simu- 
 late Paget's disease, can be differentiated only by means of biopsy. 
 
 Fig. 79. — Paget's disease of the nipple. After a cast in the Museum of the St. Louis 
 Hospital, Paris. 
 
 The histology of Paget's disease shows a Malpighian layer inter- 
 spersed or even packed with vacuolated cells and round bodies, 
 as well as cells with deformed, sometimes monstrous nuclei; their 
 large numbers as well as the acantholysis of the intermediate 
 cells, gives the epidermis a disorganized appearance and leads to 
 the production of oozing or crusted erosions. The scales which 
 persist, appear under the microscope dotted with vacuoles and 
 pseudococcidia. The papillary body is infiltrated with plasmocytes, 
 sometimes arranged in a continuous layer. 
 
 The threatened contingency of cancer necessitates the treatment 
 
230 KERATOSES 
 
 of Paget's disease by [radical] surgical measures. Radiotherapy lias 
 been tried, without success. 
 
 Precancerous Dermatosis of Bowen or Dyskeratosis Lenticularis 
 et Discoides. —I have recommended that the name of J. T. Bowen 
 be attached to an essentially chronic and progressive derma- 
 t * » — i — first described by him in 1912. It appears in the form of 
 lenticular or nummular disks (Fig. ml. later patches of irregular 
 shape, covered with thick scaly crusts; the lesions are generally 
 multiple, non-symmetrical, and may be situated anywhere. Atro- 
 phic spots, resembling Paget - - disease, may also be seen. 
 
 Fig. 80. -Dyskeratosis <>f Bowen. showing a patch composed of lenticular and dis- 
 coid lesions on the internal malleolus of a woman, aged thirty-nine years. Personal 
 observation, 1914. 
 
 The histological structure of the lesion is entirely analogous with 
 that of Paget's disease, especially in regard to the dyskeratosis and 
 the vacuolization; but in Bowen's disease a well-marked hyper- 
 keratosis is demonstrable. The differential diagnosis from psoriati- 
 form eczematides, tertiary syphilides, psoriasis, senile keratosis 
 Lupus erythematodes, certain forms of lichen, etc., must be con- 
 fin mi 1 by biopsy. 
 
 In one-half of the reported cases, the affection was observed to 
 degenerate into cancer. Hence, there is good reason for expressly 
 recommending the total destruction, or better, the surgical removal 
 of the diseased areas. 
 
CHAPTER XII. 
 PAPILLOMATOUS AND PROLIFERATING DERMATOSES. 1 
 
 Papillary proliferations are more or less prominent excres- 
 cences, which may be conical, filiform, or resembling a cauliflower 
 growth, arranged in patches or spread out over large areas. 
 
 They must not be interpreted as resulting simply from the 
 elongation of preexisting normal papilke; on a given surface the 
 normal papillae are actually infinitely more numerous than the 
 excrescences which can lodge there. Each proliferation really 
 corresponds to several papilla?, united on the same axis or connective 
 tissue vascular stalk. 
 
 The anatomical conditions which give rise to the phenomenon 
 of papillary proliferation can be explained in three different ways: 
 It may result from an active primary proliferation of the upper 
 layer of the derma known as the papillary body, or from a primary 
 proliferation of the rete Malpighii; or from a simultaneous hyper- 
 trophy of these two layers. As a general rule, as was demonstrated 
 by Auspitz, the Malpighian hyperplasia, known as acanthosis or 
 hyperacanthosis, is the original disturbance. It is not understood 
 why this gives rise sometimes to a simple epidermic papule (for 
 instance, the flat juvenile wart), sometimes to a papillomatous 
 elevation (for instance, the papillary wart). 
 
 The horny layer which covers the proliferations may have its 
 normal thickness, or it may be thinned, as in the venereal warts; 
 or on the contrary, thickened as in common warts. Hence, there 
 are naked proliferations with a smooth pink surface; others have 
 the normal color of the skin; still others are of a grayish yellow color, 
 firm consistence, and evidently hyperkeratotic. The latter are 
 named verrucosities or verrucous excrescences. 
 
 No very distinct boundary line can accordingly be established 
 between the two dermatological forms of keratoses and verrucosities. 
 
 As regards the term papilloma, this approximately corresponds to 
 
 1 In the original, this chapter is headed vegetations et dermatoses vegetantes. 
 These terms cannot be literally transcribed into English. The term vegetation con- 
 notes a papillary proliferation for which the word papilloma was formerly used. But 
 as Virchow long ago pointed out, this term is unscientific; the condition is not a 
 tumor of the papillary body but rather a proliferation of the interpapiliary epithelial 
 processes with secondary changes in the papillae. The adjective papillomatous, 
 however, may properly be used to indicate this clinical condition. — Ed. 
 
238 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 
 
 that of vegetation, and like the latter does not designate a dermato- 
 logical type or species, but an objective appearance which may be 
 brought about in a variety of dermatoses and tumors. 
 
 Papillomatous Dermatoses. — These can be divided into three 
 groups : 
 
 A. Essential Papillomatous Dermatoses. — Some are circumscribed, 
 like the venereal warts, which will be discussed in a special para- 
 graph; the same is true for common wafts. 
 
 The verrucous nevi have been mentioned in connection with the 
 circumscribed keratoses and will figure again among the nevi in 
 general (XXXI). 
 
 Others are generalized or regionally diffused. It is sufficient to 
 recall the hystrix varieties of ichthyosis and generalized hyper- 
 keratosis. Under this heading belongs a peculiar cutaneous dys- 
 trophy, known as acanthosis nigricans. 
 
 B. Accidentally Papillomatous Dermatoses. — Several skin diseases, 
 of infectious, toxic, or indefinite character, may present proliferations 
 as a form of eruption, as an accidental manifestation, or as a develop- 
 mental phase. From the diagnostic point of view, it is important 
 to compare them with each other. 
 
 C. Tropical Proliferating Dermatoses. — The establishment of this 
 group may appear unscientific; but it is justified in the present 
 state of our knowledge and, moreover, is convenient. 
 
 VENEREAL WARTS. 
 
 Also named condyloma acuminatum and popularly known [in 
 France] as cauliflower growths, cock's comb, etc., venereal warts 
 are agminated papilliform excrescences, of a pinkish or grayish 
 color, having their seat of predilection about the genital organs and 
 the neighboring folds. 
 
 In men, they are almost exclusively situated in the glando- 
 preputial groove, on the corona glandis and the frenum, but may 
 affect the entire prepuce and the urethral orifice. 
 
 In women (Fig. SI) they affect the vestibule of the vulva, the 
 fourchette, the preputium clitoridis and sometimes cover the entire 
 vulva, the genito-crural folds, the anus and the intergluteal region. 
 
 At the onset, the lesions are simple pinkish granules or branching 
 elevations, like a mole's paw; as they grow they form tufts of fili- 
 form or lamellar processes, sometimes reaching a length of several 
 centimeters. Whether sessile or pedunculated, the warts originate 
 on a healthy unthickened skin or mucosa, which is sometimes irri- 
 tated or macerated. In women who are neglectful of cleanliness, 
 especially in case of gonorrhea and pregnancy, they finally form 
 enormous mammillated masses the size of a fist, bright red in color, 
 
VENEREAL WARTS 
 
 239 
 
 oozing and offensive. They cause inconvenience but no actual pain. 
 They may be found very rarely in the axillae and on the scalp, but 
 not elsewhere. 
 
 The histology of these growths shows a very pronounced hyper- 
 acanthosis, with abundant karyokineses, covering filiform and 
 branched connective-tissue protuberances which are traversed by 
 bloodvessels with large lumina. There may be no suggestion of 
 acute inflammation in these tissues. The granular layer is dis- 
 continuous, the horny layer is very thin. 
 
 Fig. 81. — Venereal warts of the vulva. 
 
 The etiology has not been elucidated; these growths are reputed 
 to be contagious and auto-inoculable; on the other hand, I have 
 certainly known them to appear without direct contagion, under 
 the influence of ordinary irritations, gonorrhea, pregnancy, etc. 
 Their kinship to common warts has been frequently suspected, but 
 has not been demonstrated. 
 
 Treatment by attention to hygiene, astringent lotions, bland 
 powders, pulv. Sabinse with an addition of salicylic acid, 2 per cent, 
 will usually cause them to wither, though not to disappear entirely. 
 Among caustic agents, pure carbolic acid, or chromic acid, may 
 prove successful when the warts are very small. 
 
 Voluminous growths require ablation with the scissors, or detach- 
 ment with the forceps, or better with a curette; the operation is 
 rather painful. Anesthesia, local or general, is sometimes necessary; 
 
240 PAPILLOMATOUS AXD PROLIFERATING DERMATOSES 
 
 inferior spinal analgesia with cocain, which deprives the region of 
 all sensation, would be very valuable in extreme eases of profuse 
 and exuberant growth. My assistant and friend Dr. Chicotot has 
 successfully removed large masses of condylomata by means of 
 radiotherapy. 
 
 VERRUCA VULGARIS. 
 
 A common wart is a papillary hyperkeratotic excrescence; it is 
 typical of products of this sort, which are accordingly known as 
 wartv or verrucous. 
 
 Fig. s2. — ( iomrnon wails on the hands of a school-boy. Note near the left thumb 
 a trail of four waits which developed on a scratch made with a pin. 
 
 A w;irt consists of a rather prominent, rounded and distinctly 
 circumscribed elevation, from the size of a pin-head to that of a 
 small bean, usually as large as a pea, of a grayish, yellowish or gray 
 black color, with a mammillated surface sometimes studded with 
 villous protuberances, of a hard rough consistence. The surround- 
 ing skin is not congested. Some warts are constricted at their base, 
 almost pedunculated, while others spread out and are not much 
 raised. They are not sensitive or painful except at the borders of 
 
VERRUCA VULGARIS 
 
 241 
 
 the finger-nails and in regions exposed to pressure, notably on the 
 soles of the feet. 
 
 Warts are usually multiple and have their seat of election on the 
 dorsal or lateral aspects of the fingers and the hand (Fig. 82), where 
 they may become confluent in patches, they also occupy the peri- 
 ungual or subungual groove; more rarely; the palm of the hand or 
 fingers, the face, the eye-lids, the scalp and the soles. 
 
 Juvenile flat warts are probably only a special form of the same 
 affection (p. 130). 
 
 Fig. 83. — Plantar warts in a girl aged twenty yeai 
 
 Plantar warts, described by Dubreuilh and M. Robert, are 
 noteworthy on account of their extreme tenderness and the special 
 treatment which they require. They are preferably situated on 
 the supporting points of the foot and at first sight resemble calluses, 
 but on closer examination, they are seen to be usually composed 
 of filiform growths, arranged in a cluster and surrounded by a raised 
 border (Fig. 83). They can be cured without much difficulty by 
 means of radiotherapy. [I have encountered some plantar warts 
 which are extremely resistant to treatment and have yielded only 
 to the actual cautery or to applications of carbonic acid snow after 
 the removal of the thick horny layer by means of strong salicylic 
 acid plasters and curettage.] 
 
 All warts may become fissured and inflamed. 
 16 
 
242 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 
 
 These formations are extremely common and are observed espe- 
 cially in schoolboys, in youthful individuals doing manual labor, 
 but also in adults. The contagiousness and auto-inoculability 
 of warts, always asserted by the laity, have been proved beyond 
 a doubt by the experiments of Variot and others; the incubation 
 lasts longer than a fortnight. The microbe is unknown; the bacillus 
 porri which has been described, has not been proved to be the 
 causative agent. [Wile and Kingery have reproduced epithelial 
 hyperplasia by injection of the filtrate made from the substance of 
 common warts.] 
 
 The histology of Avarts shows an enormous increase in the length 
 of single papillae or of groups of papilla? and of their vessels and a 
 considerable thickening of all the layers of the epidermis; there is 
 no inflammatory infiltration in the cutis. 
 
 The treatment must aim at the avoidance of cicatrices, for 
 the warts often disappear spontaneously. It is most advisable to 
 cauterize them carefully with the galvanocautery, or with a very 
 fine point of thermocautery, assisted by the curette. Carbonic 
 acid snow, properly applied, is likewise very successful. Radio- 
 therapy gives remarkable results, without pain; but it requires 
 great caution, especially on the back of the hand. 
 
 Electrolysis has been recommended in case of large warts and 
 magnesium ionization when they are very numerous; and, very 
 recently, solar light condensed by means of a large lens. It is 
 difficult to determine the efficacy of the daily administration of 75 
 centigrams of magnesium, or of a few r drops of tincture of thuja, 
 or of arsenical medication. 
 
 Nitric acid does not deserve the favor which it enjoys, for it has 
 caused innumerable burns and distressing scars. Less powerful 
 caustic agents, collodium, plasters, etc., are apt to be disappointing. 
 The juice of the milk-wort and of the celandine, very persistently 
 applied, causes the warts to wither and drop off. 
 
 These various measures may prove successful, but it is important 
 to keep in mind a surprising but undeniable fact, stated by many 
 writers, namely, that simple suggestion may have the same effect. 
 
 [After persisting for a variable period, months or years, warts 
 generally disappear without any known reason.] 
 
 PAPILLARY AND PIGMENTARY DYSTROPHY OR ACANTHOSIS 
 NIGRICANS. 
 
 This disease was described under the latter name by Pollitzer 
 and Janovski, in 1890, after I had observed and named it papillary 
 and pigmentary dystrophy [but had not published the observation]. 
 It is characterized by two fundamental phenomena: (1) a roughened 
 condition of the skin, with scattered or agminated papillomatous 
 
PAPILLARY AND PIGMENTARY DYSTROPHY 
 
 243 
 
 elevations; and (2) a dark pigmentation. The lesions are essentially 
 regional, ordinarily symmetrical, with somewhat diffuse borders. 
 In order of frequency, they affect the axillae, the neck and nape of 
 the neck, the ano-genital region, the internal aspect of the thighs, 
 the fold of the elbow, the popliteal space, the umbilicus, the back 
 of the hands, the areola of the breasts and the feet. 
 
 The roughened condition of the integument is due to an exaggera- 
 tion of the folds and fissures and does not disappear on stretching 
 the skin; from this surface, which is studded with papillary pro- 
 tuberances, of a brown or even black color comparable to the bark 
 of a tree, but supple and sometimes scaly, arise sessile or peduncu- 
 
 Fig. 84. — Acanthosis nigricans, of five months' standing; portion of the supra- 
 clavicular fossa of a man aged forty-two years, suffering from cancer of the liver. 
 After a cast by Baretta. 
 
 lated papillomatous proliferations (Fig. 84), isolated or in patches; 
 on the free border of the eyelids and lips, they may present a regular 
 arrangement like the teeth of a comb. 
 
 In the palmar and plantar regions, the normal papillary ridges are 
 notably exaggerated. The tongue is nearly always villous, but the 
 mucosae are never pigmented. 
 
 The finger nails are brittle, generalized alopecia is common; 
 pruritus has occasionally been noted. 
 
 Acanthosis nigricans is a rare disease, about sixty [at least eighty 
 to a hundred] observations have been reported from all countries, 
 with a slight predominance of the female sex. Its principal interest is 
 
244 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 
 
 due to the fact that very frequently, in about two-thirds of the cases, 
 it. is associated, as was first pointed out by me, with a cancer of the 
 abdominal cavity, primary carcinoma of the stomach or intestines, 
 for instance, or it may be secondary to a cancer of the uterus, or the 
 breast, etc. This dermatosis may accordingly put the physician on 
 the track of a latent cancer, as has happened in several instances. 
 
 It begins with a dirty-looking pigmentation of the neck and axilla?, 
 or the appearance of one or several warty growths. The course 
 is rapidly progressive, sometimes interrupted by remissions, and 
 cachexia supervenes in less than a year, two years at most. 
 
 This so-called grave form, which occurs after the age of thirty 
 years, may be contrasted with a juvenile or benign form, developing 
 in children, not related to cancer and only half as frequent. The 
 symptoms are usually not so marked and are more stationary; the 
 duration is indefinite, but the general health is not affected. The 
 pathogenesis is unknown. 
 
 The atypical forms which have been described, can be admitted 
 only conditionally and may possibly be referred to ichthyosiform 
 hyperkeratosis or analogous conditions. 
 
 Accidentally Proliferating Dermatoses. — Proliferating lesions may 
 occur in a large number of acute or chronic, generalized or localized 
 cutaneous affections of very variable character. The territory, or 
 the affected tegumentary region is sometimes responsible. It is 
 obvious, although this fact seems to have escaped the attention 
 of most writers, that the peri-anal, peri-genital, inguinal, axillary 
 regions, in short the large folds, and on the other hand the borders 
 of the orifices of the face, the scalp and to a less degree the extremi- 
 ties are especially subject to the occurrence of papillary prolifera- 
 tions. It is also possible that certain infectious agents have a 
 tendency to excite proliferation; several pathogenic protozoa 
 apparently possess this property. 
 
 The assumption is, moreover, justified that the papillomatous 
 character which various eruptions may accidentally develop, is 
 referable to a secondary infection or a microbic symbiosis. 
 
 Pemphigus Vegetans Gravis. — This pathological type was described 
 in L876 by J. Neumann, who considered it as a distinct disease. It 
 is characterized by bulla' on the Moor of which papillomatous 
 growths very promptly make their appearance. The eruption is 
 situated especially in the groins, in the large articular folds and at 
 the circumference of the mouth. It often begins on the buccal or 
 pharyngeal mucosa, or at the genital organs; sometimes at the 
 border of the finger-nails [or at the anus]., 
 
 The initial lesion is a bulla, often flaccid and seropurulent from 
 the first, which dries into a crust and may heal locally or spread 
 at the periphery. At the end of five or six days, the floor of some 
 
PAPILLARY AND PIGMENTARY DYSTROPHY 245 
 
 or most of the bullae becomes excoriated, begins to proliferate, 
 undergoes a papillomatous change and secretes an offensive pus 
 under a brownish crust. There is a striking resemblance between 
 these lesions and hypertrophic mucous patches. Serpiginous 
 extension and confluence of the lesions give rise to extensive sur- 
 faces, mammillated in the center and pustular at the circumference. 
 Healing is followed by brownish and roughened macula?. 
 
 In severe cases, the mouth is lined with very painful diphtheritic 
 erosions, the lips, all the articular folds and the regions where skin 
 rests upon skin, sometimes a considerable portion of the head, 
 trunk and limbs, as well as the mucous membranes, are covered 
 with fetid and painful suppurating vegetating ulcerations. Fever 
 has been repeatedly noted. Death supervenes from cachexia in 
 two to six months, sometimes later. 
 
 The histology of the initial bulla is that of genuine pemphigus. In 
 the papillomatous stage, the excrescences, which may reach a height 
 of 6 to 10 millimeters, are covered with a greatly thickened rete 
 Malpighii. In the latter, or in the proliferating papillary body, or 
 between these two tissues, small abscesses are demonstrable, with 
 polynuclear leukocytes and numerous eosinophile cells. Fosino- 
 philia have been demonstrated in the blood and various lesions of 
 the nervous system and the viscera have been found at autopsies. 
 Pemphigus vegetans gravis is observed in both sexes, especially in 
 adults, but it is a rare disease. Its nature is unknown. Its unfav- 
 orable course and gloomy prognosis suggest that it is merely a 
 variety of genuine pemphigus, which has become papillomatous 
 through a superadded infection with an undetermined agent. G. 
 Pernet (1907) is undoubtedly right in claiming that pemphigus 
 vegetans is not a definite pathological variety, but is referable to a 
 number of infectious agents among which he states the Bacillus 
 pyocyaneus to be especially common. [The pyocyaneus, however, 
 is extremely common everywhere!] 
 
 Pemphigus Vegetans Benignus. — Beside the above described almost 
 invariably fatal form, an eruption is sometimes observed having 
 very similar lesions, but advancing in successive attacks, with 
 preservation of a good general condition and terminating in recovery 
 after a variable length of time. In this benign form, the mouth, 
 lips and large folds are not so much involved ; whereas the skin of the 
 extremities and the large surfaces of the trunk (Fig. 85) suffers more. 
 
 There is a striking similarity with bromoderma and iododerma 
 vegetans. 
 
 The coexistence of polymorphous eruptive lesions and eosinophilia 
 of the blood has often been interpreted as pointing to a prolifera- 
 tive form of Duhring's disease. Non-recurrent cases have on the 
 other hand suggested the idea of erythema bullosum vegetans. 
 
240 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 
 
 On the whole, the scries of forms of pemphigus vegetans presents 
 the same difficulties of classification as the bullous eruptions in 
 general. Some dermatologists simplify the problem by recognizing 
 a dermatitis vegetans capable of assuming every imaginable degree. 
 
 Treatment. The treatment is that of infected erosions of all 
 kinds: prolonged local baths, softening or mildly antiseptic moist 
 dressings, with hypochlorites, permanganate, etc., painting with 
 iodin solution, application ^of absorbent powders. Arsenic and 
 especially arsenobenzol have yielded some very satisfactory results. 
 Radiotherapy is likewise successful. 
 
 Fig. 85. — Benign pemphigus vegetans; patch of five months' standing in a 
 child aged five years; blood withdrawn from the lesions contained 30 per cent. 6f 
 eo M,. iphiles. 
 
 Proliferating Pyodermatitides. — Under the name of chronic pustular 
 dermatitis in feci with peripheral extension, later as pyodermatitis 
 vegetans, Hallopeau I L889 ISDN) described a form which is pustular 
 from the onset, benign in character, slowly progressive and very 
 protracted, as a variety of Neumann's pemphigus vegetans. 
 
 The name of pyodermatitis vegetans might also be applied to the 
 cases in which an impetigo or an infected herpes, etc., give rise to 
 papillomatous proliferations, which is especially apt to occur in 
 the folds. (Sec Syphiloid Dermatitis Vegetans.) 
 
 Papillomatous and Verrucous Elephantiasis.- — In all forms of 
 elephantiasis, especially in elephantiasis nostras and still more in 
 the secondary elephantiases, the cutaneous surface, chiefly on 
 the lower part of the legs and on the feet, may become roughened, 
 
PLATE I 
 
 Vegetative Syphilides of the Secondary Stage. 
 
 The patient presented at the same time vegetative mucous patches upon 
 the lips and under the tongue. 
 
PAPILLARY AND PIGMENTARY DYSTROPHY 247 
 
 mammillated, covered with pink or whitish proliferations, or with 
 gray or blackish hyperkeratotic verrucosities. 
 
 Hypertrophic Lichen Corneus. — This affection, which is very 
 easily recognized after seeing a case, has been described above 
 (p. 140). 
 
 Papillomatous Syphilides. — These are either secondary or tertiary. 
 The secondary kind constitute a modification of the lenticular or 
 especially the nummular papules. Generally isolated or not 
 numerous, they occupy the nape of the neck (Plate I), the thorax 
 or the face and assume the shape of distinctly circumscribed, 
 sometimes crusted papillomatous patches, 0.5 cm. thick, from 1 to 
 4 cm. wide, developing gradually and leaving a dyschromic spot. 
 They are not rare in the nasogenial furrow and at the fold of the 
 chin. 
 
 Hypertrophic mucous patches belong entirely under this heading. 
 The syphilitic patches of Legendre are related lesions. 
 
 Tertiary proliferating syphilides may develop on a variety of 
 ulcerations, especially on tuberculo-gummous syphilides. In these 
 cases, papillomatous or fungoid papillomatous growths are seen 
 arising from the depths of solutions of continuity, radically altering 
 the appearance of the lesions. This contingency must be kept 
 in mind, for tertiary proliferating syphilides are often confused 
 especially with epitheliomas. They are observed more particularly 
 in hairy regions, the scalp, beard, axilla, pubis and on the lower 
 limbs; they may accompany an elephantiatic state. 
 
 Papillomatous and Verrucous Tuberculosis. — The cutaneous tuber- 
 culous lesions are proliferative under various conditions. Irregular 
 patches of ulcerative papillomatous tuberculosis may be observed, 
 although not commonly, either at the circumference of the mouth 
 or at the anus, or finally at the vulva, where they are sometimes 
 considered as part of the syndrome of vaginal lupus. Pinkish or 
 papillomatous proliferations arise from the floor or the border of 
 the ulceration. The course is extremely slow. 
 
 From time to time, cases of frambesif orm tuberculosis are reported, 
 representing large surfaces covered with villous proliferations and 
 interspersed with irregular ulcers and miliary abscesses. A lesion 
 of this kind, which covered almost the entire extent of the thigh 
 and buttock was observed by myself and Brocq. 
 
 Tuberculosis Verrucosa. — Tuberculosis verrucosa is more common, 
 and is entitled to a detailed description. It is usually found on 
 the hand, on the fingers or on the wrists; it has a certain predilec- 
 tion for the radial side of the hand and especially for the thumb 
 (Fig. 86) ; but it is also met with on the elbows, the knees, in the 
 peri-anal region, on the buttocks, the feet, the neck and even on- 
 the face. It appears in the form of a single patch, of nummular 
 
248 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 
 
 dimensions or more extensive, of a round, oval or multilobular 
 configuration, sometimes elongated, following a fold of the skin. 
 
 When the focus is small, it is a papillomatous or hyperkeratotic 
 elevation, somewhat resembling- a wart; but its base is always 
 surrounded by a red or purplish areola; pressure will occasionally 
 cause a small drop of pus to escape. 
 
 In its completely developed state, a patch of verrucous tuber- 
 culosis is composed of three zones: at the circumference, a smooth 
 and level erythematous zone; next, a more elevated, purplish or 
 brownish, papillomatous median zone, interspersed with small 
 adherent crusts or cribriform ulcers, from which droplets of pus 
 can be squeezed out; finally, a central portion, which is sometimes 
 cicatricial and depressed, sometimes protuberant and studded with 
 gray or yellowish horny verrucosities, separated by grooves and 
 fissures. The base of the patch is indurated, of fibrous rather than 
 edematous consistence. 
 
 Fig. 86. — Tuberculosis verrucosa. After a cast of Baretta's in the Museum of the 
 St. Louis Hospital. 
 
 After healing has occurred, the cicatrix is flat and white, or 
 undulating and interspersed with light tracts on a purplish back- 
 ground. It is adherent when the cutaneous lesion was derived 
 from a deep, bony, or glandular focus, etc. 
 
 The diagnosis of tuberculosis verrucosa, based on its objective 
 features, its seat, the conditions under which it appears, and its 
 slow course, is usually easy. Examination by biopsy, bacteriolog- 
 ical examination and experimental inoculation will serve to confirm 
 it in those cases where syphilis, epithelioma, sporotrichosis, the 
 blastomycoses, etc., cannot be readily excluded. 
 
 Anatomical tubercles may be regarded as a verrucous tubercu- 
 losis, of small dimensions, but highly virulent. 
 
 Discussion of the etiology and treatment of these affections will 
 be found elsewhere in this book (p. 552). 
 
PROLIFERATING TROPICAL DERMATOSES 249 
 
 Proliferating or Papillomatous Epithelioma. — This is observed 
 chiefly in the face, especially on the lips or on the mouth and also 
 on the external genital organs. 
 
 This papillomatous epithelioma often develops on a basis of 
 senile keratosis or leukoplakia. Surgical excision, as promptly as 
 possible, is indicated. 
 
 Mycoses, Sporotrichoses, Etc. — An appearance identical with or 
 closely analogous to that of papillomatous syphilides, papillomatous 
 epithelioma, and especially tuberculosis verrucosa, may be pro- 
 duced by a blastomycotic or sporotrichetic infection. At the 
 present day, when the frequency of the mycotic dermatoses has 
 been established, especially through the work of de Beurmann and 
 Gougerot, it would be a serious error not to take this possibility 
 into consideration, whenever it is plausible. The investigations 
 required for its verification will be discussed elsewhere. 
 
 Papillomatous Toxicodermas. — Iododerma papillomatosum may 
 appear in any region of the integument, beginning as a purulent 
 bulla with an inflammatory base, which becomes papillomatous at 
 the center and rapidly extends peripherally. The usually multiple 
 lesions become confluent in sometimes rather extensive patches; 
 their pustular margin is suggestive. 
 
 Bromoderma papillomatosum greatly resembles the iodide erup- 
 tion, but is softer, more fungoid, with less tendency to suppurate. 
 
 In both cases, in the absence of definite information, iodin or 
 bromin may be looked for in the urine. It is noteworthy, however, 
 that these eruptions may persist several weeks after the last inges- 
 tion of the drug. [In the case of nursing infants the eruption may 
 develop in consequence of a bromide or iodide mixture taken by 
 the nurse.] 
 
 PROLIFERATING TROPICAL DERMATOSES. 
 
 A group of diseases endemic in tropical countries is characterized 
 by proliferating or ulcero-vegetative eruptions. 
 
 Their objective appearance is sometimes typical, but they are 
 nevertheless apt to be confused, especially with tuberculosis and 
 syphilis. In a general way, it may be stated that tuberculosis 
 verrucosa differs by its slow course and the small number of foci 
 which never heal spontaneously; and syphilis, by its polymorphous, 
 protean manifestations, which do not spare the mucosae and which 
 follow a definite course. 
 
 In most cases, a valuable diagnostic indication is furnished by 
 the mode of origin, the disease appearing either in the country 
 where it prevails, or in returning travellers. 
 
250 PAPILLOMATOUS AXD PROLIFERATING DERMATOSES 
 
 Oriental Boil (Biskra Button). — In its developed stage, the Biskra 
 button (p. 648) is a round or oval ulceration, the size of a small 
 coin or several centimeters in diameter, with festooned outlines, 
 concealed under a very adherent yellow-brown crust and bordered 
 by an erythematous margin (Fig. 186). 
 
 Under the crust is found a turbid serous fluid, an ulcer with 
 perpendicular eroded ragged margins and a bright-red, granular, 
 mannnillated and papillomatous floor. On this floor and around 
 the circumference, purulent yellow points may be found. The 
 base is congested and infiltrated. Lymphangitis and phlebitis are 
 frequent complications. The glands are as a rule enlarged and 
 painful. 
 
 Spontaneous cicatrization is slow, requiring several months. 
 The scar which persists is depressed, smooth, colorless or of a dusky 
 red hue, with peripheral pigmentation. 
 
 The histological structure is that of a granuloma, with predomi- 
 nance of mononuclears, a few plasmoeytes and foci of necrosis. 
 The papillary hypertrophy is considerable, with hyperacanthosis 
 and parakeratosis. 
 
 Yaws. — The eruptive lesion in yaws or Frambesia tropica, in the 
 primary lesion as well as in the generalized eruption, always consists 
 at the onset of a rose-red conical elevation, with a crusted necrotic 
 center; the crust is discharged, the lesion extends and becomes 
 papillomatous (p. 646). 
 
 The patches may attain a diameter of 1 to 6 cm.; they are covered 
 with an adherent brown crust, or a fetid secretion in the macerated 
 areas. The proliferations are grayish or pinkish ; there is no ulcera- 
 tion or loss of substance. The center has a tendency to collapse; 
 the circumference is often the seat of a bullous elevation. Con- 
 fluence gives rise to the formation of large patches with polycyclic 
 outlines. The eruption is usually painless. 
 
 A spontaneous cure may occur at any stage of development; it 
 manifests itself by the lesions becoming flattened and undergoing 
 absorption. Only pigmented macules are left behind, and, as a 
 rule, no cicatrices. 
 
 The site of election of the eruptions in yaws is around the natural 
 orifices, at the lips, the nostrils, in the genital regions and in all 
 body folds. But they may be very extensive and profuse, suggest- 
 ing hypertrophic mucous patches and papulo-crusted syphilides. 
 In the palmar and plantar regions, the proliferations are covered 
 with hyperkeratoses and are very painful. The mucous mem- 
 branes always remain free. 
 
 Histology shows an abundant infiltration of plasmoeytes, without 
 epithelioid cells or giant cells; it occupies the papillary body and 
 the papilla-; the latter are enormously hypertrophied and traversed 
 
PROLIFERATING TROPICAL DERMATOSES 251 
 
 by dilated vessels. Hyperkeratosis is considerable and parakeratosis 
 is common. 
 
 Elsewhere mention will be made of the proliferative papilloma- 
 tous ulcers of Boubas, which are accompanied by similar lesions of 
 the mucous membranes (p. 650). 
 
 Ulcerating Granuloma of the Genital Organs (Granuloma 
 Inguinale, Granuloma Venereo, Groin Ulceration). — This is a chronic 
 and contagious, ulcerative or papillomatous dermatosis, venereal 
 in most cases, occurring in all countries, notably in South America, 
 especially in Guiana and Brazil, as well as in New Zealand and 
 the East Indies; a few cases have been reported in England. It 
 attacks adults of both sexes and all races. 
 
 Beginning with a nodule on the genital organs, it spreads in the 
 form of an ulcerative granular patch to the groins, the pubis, the 
 perineum and invades the mucosae. The borders are distinctly 
 marked; the surface is riddled with papillomatous elevations, super- 
 ficially ulcerated, of a bright red color; it secretes an offensive serous 
 fluid; the center becomes cicatricial. This lesion lasts many years, 
 without causing glandular enlargement or giving rise to cachexia. 
 
 Histologically, it is a plasmoma with enormous hypertrophy of 
 the papillae, analogous to yaws. According to a very recent and 
 excellent contribution by Souza Araujo (Rio de Janeiro, 1917), the 
 causative agent seems to be the germ discovered by Donovan in 
 1905, which has since been isolated and cultured and is known as 
 Calymmato-bacterium grannlomatis. This encapsulated bacillus is 
 Gram-negative, takes the Giemsa stain and is abundantly present 
 in the cells of the granuloma and in the secretion. The specific 
 treatment of the disease consists of intravenous injections of 
 tartar emetic. 
 
CHAPTER XIII. 
 
 TUBERCLES AND TUBERCULO-ULCERATIVE 
 
 DERMATOSES. 
 
 In the dermatological [as distinguished from the pathological] 
 sense of the word, tubercles are pathological products of the cutis, 
 solid (that is, without fluid contents), circumscribed, rounded, more 
 or less prominent, of slow development, deep and especially damag- 
 ing to the cutis. 
 
 This last named and most essential characteristic involves a 
 frequent tendency of tubercles to ulcerate and almost always to 
 leave a cicatrix in their place, with or without previous ulceration. 
 This fact is expressed in the statement that tubercles do not undergo 
 resolution. 
 
 The differentiation of tubercular eruptions from papules, nodules 
 and tumors, must first be clearly understood. Papules are dis- 
 tinguished from tubercles, not so much by their size and prominence, 
 as by their more rapid development and tendency to absorption, a 
 papule leaving no scar behind it after it has healed. Doubtful or 
 intermediate lesions are met with, however, which may be named 
 papulo-tubercles; some dermatologists use this term for giant papules. 
 
 Nodes and nodules are hypodermic newformations, whereas 
 tubercles are dermic. But, although morphologically distinct, 
 tubercles and nodules often result from the same process, justifying 
 the terminology of Besnier, who defines nodules as hypodermic 
 tubercles. 
 
 Certain tubercles simulate tumors, or approximate these by their 
 size, prominence, confluence in raised and mammillated patches, 
 course, etc. Tubercles, however, after a more or less prolonged 
 duration, have a tendency to become replaced by a cicatrix; tumors, 
 on the contrary, are persistent or indefinitely progressive, although 
 these features are not invariable. 
 
 In reality the basis of differentiation is that the name of tumors 
 is given to newgrowths of entirely unknown character, while 
 dermic neoplasms of a known chronic infectious origin are known 
 as tubercles. 
 
 The histological criterion is decisive in this connection. As will 
 be seen further on (Chapter XXXI), tumors are composed of 
 heterotopic tissues which replace the normal tissue of the affected 
 
TUBERCULO-ULCERATIVE DERMATOSES 253 
 
 region. Tubercles, on the contrary, are formed" by collections of 
 inflammatory cells of various types, more or less coherent and 
 extensive, infiltrating the strands of the derma which may have 
 undergone degenerative changes. 
 
 The abundance and density of these cellular infiltrations and 
 the degree of preservation of the dermic stroma are variable and 
 account for the more or less marked prominence, firmness or soft- 
 ness of the tubercles. Their constitution also serves to explain 
 their capacity of undergoing absorption, although usually not 
 without atrophy and sclerosis, that is, not without a cicatrix. 
 
 In some tubercles, the infiltration has a marked tendency to 
 cellular necrosis, disintegration and dissolution naturally following; 
 the outcome is a limited and often very deep ulceration. 
 
 The differential diagnosis between a tuberculo-ulcerative process 
 and primary ulcerations rests on its at first neoplastic and second- 
 arily destructive course; furthermore, on the usual persistence of 
 tubercular remnants at the base and in the circumference of the 
 ulcer, indicated by a special hardness in the case of tertiary 
 syphilides or actinomycosis, by a peculiar softness in the case of 
 ulcerative lupus, etc. 
 
 Indurated follicular pathological products, whether suppurative 
 like furunculosis and carbuncle, or dry like keloid acne, do not figure 
 in this book among the tubercles, but in the chapter on the folli- 
 culoses (Chapter XIX). 
 
 TUBERCULO-ULCERATIVE DERMATOSES. 
 
 The presence of true tubercles or of a tuberculo-ulcerative lesion 
 having been recognized, it is necessary to think in the first place of 
 the great chronic infectious diseases, i. e., syphilis, tuberculosis 
 and leprosy; secondarily, of the more uncommon mycotic infections, 
 such as sporotrichosis, the blastomycoses and actinomycosis, for 
 which the reader is referred to another chapter (XXVIII) ; finally, 
 there is a group of dermatoses manifesting itself by non-ulcerative 
 tubercles, the lupoid and analogous cutaneous sarcoids, which are 
 undoubtedly of infectious character and probably belong to the 
 tuberculides, although this has not been positively established. 
 
 Only the following types will be described in this connection: 
 (1) The tubercular syphilides, (2) the tubercles of lupus, (3) the 
 tubercles of leprosy, (4) the cutaneous sarcoids or lupoids and granu- 
 loma annulare. 
 
 Tubercular Syphilides. — From the purely morphological view- 
 point, leaving the course entirely out of consideration, the initial 
 symptom of syphilis, the hard chancre, might be said to present 
 the chief attributes of a tubercle. 
 
2.14 TUBERt 'LES AND TUBERCULO-ULCERATIVE DERMATOSES 
 
 Genuine tubercular syphilides, however, are symptoms of the 
 tertiary stage. 
 
 The syphilitic tubercle constitutes the typical form of a tubercle. 
 It is a dry elevation, brownish or grayish red in color, the average 
 size of a lentil, projecting from 1 to 5 mm., with rounded contours, 
 very hard on palpation, entirely painless. On vitropressure (mean- 
 ing when the tubercle is com prosed under a glass slide), it is seen 
 to be opaque and frequently pigmented. 
 
 The subjoined illustration (Fig. 87) conveys an idea of its histo- 
 logical structure. 
 
 Fig. 87. -Histologyof syphilitic tubercle. Tuberculo-squamous tertiary syphilis. 
 
 The infiltrate (i, i) is discontinuous, composed of lymphoid cells and plas- 
 mocytes without gianl cells or epithelioid •■ell-: it forms cuffs which surround ihe 
 ramifications of the bloodvessels; these are for the most pari dilated, inflamed, or 
 sclerotic Between the infiltrates the dermic tissue (d) is thickened, fibrous and 
 sclerotic, which explains the hardness of the lesion. The horny epidermis (c) is greatly 
 thickened and coherent; at (s) it is split and shows a tendency to desquamation. 
 The Malpighian layer and the papillae are preserved, excepl at (u), where the inflam- 
 mation is more active and ulceration is under way. See Pathological Anatomy of 
 the Syphilides, p. 628. X 20. 
 
 A tubercular syphilitic begins as a single lesion or as a small 
 coherent group of tubercles which spread out, progressing excen- 
 trically and multiply within a few weeks; in this way, more or 
 less extensive patches are formed or even larger areas may become 
 involved. Usually, however, the central lesions flatten, fade and 
 undergo sclerotic changes, forming cicatrices even in the complete 
 absence of ulceration, while new lesions make their appearance 
 at the periphery. This centrifugal or serpiginous development 
 
TUBERCULO-ULCERATIVE DERMATOSES 
 
 255 
 
 gives rise to circinate forms; these are by no means complete rings, 
 but generally more or less semicircular, having a diameter of 2 to 
 12 cm, or kidney-shaped and, through confluence, polycyclic con- 
 figurations (Fig. 88). Their border is marked by a usually inter- 
 rupted zone of isolated or confluent tubercles. 
 
 Occasionally, the eruption of syphilitic tubercles may present this 
 circinate arrangement from the start. In these cases, the central 
 area shows normal skin. When the circination is the result of 
 centrifugal extension of the process, its center is, on the contrary, 
 often depressed, slightly adherent and not readily folded; it may be 
 distinctly sclerotic or interspersed with cicatricial stars and streaks; 
 its color is earthy rather than white, often mottled with purplish or 
 
 Fig. 88. — Tuberculo-circinate syphilides of the left hip. 
 
 brownish shades. The reappearance of tubercles on the cicatrix 
 is rare in the tuberculo-circinate syphilides; whereas, on the con- 
 trary, this occurrence is frequent in lupus serpiginosus. 
 
 After recovery, the tubercular border has disappeared, but the 
 persisting cicatrix may still present a very characteristic appear- 
 ance. 
 Various forms of tubercular tertiary syphilides may be described : 
 The tuber culo-squamous form, with grayish, more or less abun- 
 dant, adherent scales, is very common, more so than the tuberculo- 
 psoriatiform variety, with abundant nacreous scales and barely 
 perceptible infiltration; it is distinguished from psoriasis by the 
 small number of the patches, their configuration [and location] and 
 sometimes by the presence of cicatrices. 
 
256 TUBERCLES AND TUBERCULO-ULCERA TI VE DERMA TOSES 
 
 When the tubercles become eroded and covered with an adherent 
 dirty brownish crust, the outcome is the tuberculo-crusted form, 
 which is connected by imperceptible transition with the tuberculo- 
 ulcerative form. In the latter, the crusts are found to cover round, 
 perpendicular-walled ulcerations containing a sanious pus. 
 
 These various forms are usually circinate. There also occurs, 
 notably on the nose, the forehead and chin, a .superficial tubercular 
 syphilide, composed of large, smooth, dusky red tubercles, which 
 may be agminated or sometimes confluent in an infiltrated patch. 
 The latter is apt very closely to simulate rosacea in the stage of 
 rhinophyma; when it appears that the center has a tendency to 
 become sclerotic and depressed, this fact furnishes a valuable 
 indication in favor of syphilis; but a careful investigation may be 
 necessary. 
 
 Certain tertiary syphilitic ulcers, characterized by their indurated 
 base, sharp outlines and their course, may be considered as tuber- 
 culo-ulcerative syphilides with indistinct and primarily confluent 
 tubercles (Fig. 98). The same remark applies to chancriform 
 syphiloma. 
 
 The diagnosis of tubercular syphilides can very often be based 
 upon their objective appearance; not uncommonly, they put the 
 alert observer on the track of an undetected long-standing 
 syphilis. In other cases, the diagnosis will be confirmed by the 
 complete examination of the patient, the anamnesis and sero- 
 diagnosis, with examination by biopsy if necessary. 
 
 Specific treatment will cure these lesions in from two to four weeks. 
 
 Lupus Tubercles. — Lupus vulgaris is one of the most attenuated 
 forms of bacillary tuberculosis of the skin. Its characteristic 
 lesion consists of a tubercle possessing certain special features. 
 
 In order to avoid the ambiguousness resulting from the double 
 meaning of the word tubercle— bacillary tubercle and dermatological 
 tubercle — it has been recommended to designate the eruptive lesion 
 of lupus as lupoma. 
 
 All cases of lupus begin as a minute lupoma, which grows 
 to the size of a pin-head, then of a lentil, while other similar 
 lesions more or less rapidly originate in its immediate circumfer- 
 ence or in its vicinity. Sometimes, lupus begins in two or three 
 distinct foci, or exceptionally in the form of an extensive eruption. 
 Lupomas may accordingly be found isolated or conglomerated in 
 patches around which a few aberrant lesions are apt to appear. 
 
 Typical I lipomas are rounded tubercles, the size of a- pin-head 
 to that of a large pea, more or less prominent, or on the contrary, 
 perfectly level with the normal skin; their color is a yellowish, 
 sometimes purplish or dusky red; their surface is smooth and 
 shining, or scaly, eroded, crusted or ulcerous; their consistence is 
 
T UBERC ULO- ULCERA TI VE DERMA TOSES 
 
 257 
 
 remarkably soft, compressible, velvety; they are easily penetrated 
 with sharp instruments; they are often tender on touch. 
 
 When a lupus tubercle is subjected to vitropressure or diascopy, 
 to drive out the blood, its tissue is seen through the glass slide 
 to be of a translucid deep yellow color, comparable to barley 
 sugar or apple jelly, distinctly outlined from the creamy white 
 surface presented by the normal derma. This pathognomonic 
 transparency of the compressed lupoma, which is due to the 
 local disappearance of the elastic and connective-tissue network 
 (Fig. 89), is easily distinguished from the opaque coloration shown 
 under the same conditions by a pigmentary spot or a soft verrucous 
 nevus. 
 
 b 
 
 f ,-.:v- ■ •■%-'• 
 
 Fig. 89.— Histology of lupus tubercle. Nodular lupoma of the cheek. Stained 
 with acid orcein and polychrome blue. The tuberculous newgrowth occupies 
 the entire thickness of the derma and results from an agglomeration of tubercles 
 such as those seen in Fig. 93. a, collection of epithelioid cells; b, giant cells; 
 
 c, infiltrate of lymphocytes and plasmocytes forming a finely granular network; 
 
 d, d, elastic and connective-tissue framework of the derma, plainly seen to be inter- 
 rupted at the level of the tubercle (accounting for the softness and transparency of the 
 latter) ; e, tense thin epidermis almost eroded on the surface of the lupoma; /, /, rows 
 of lupous infiltration, seen extending into the hypoderm or (/') around a hair 
 follicle. X 15. 
 
 Lupoma, as a rule, has a tendency to persist indefinitely, gradu- 
 ally extending at its periphery and becoming confluent with neigh- 
 boring lesions. The duration of its course extends over months, 
 years or decades. However, even in the absence of all therapeutic 
 intervention, two contingencies may arise: 
 
 Some cases, so-called resolving lupus, will heal spontaneously 
 and become cicatrized, the interstitial sclerosis more or less 
 completely strangling and extinguishing the cellular newforma- 
 17 
 
258 TUBERCLES AND TUBERCULO-ULCERATIVE DERMATOSES 
 
 tion. This spontaneous cicatrization usually takes place in 
 the center of the patch, while the border continues to proliferate 
 (Fig. 168); lupomas are often seen to persist or reappear in the 
 cicatrix, which is smooth, white, pearly and more or less flexible. 
 This last-named fact is of positive diagnostic value in the differen- 
 tiation from circinate and serpiginous syphilides. The treatment 
 of lupus by scarification, punctate cauterization, light- and radium- 
 therapy, etc., aims at stimulating and favoring the process of 
 cicatrization, which is the natural mode of cure. 
 
 On the other hand, the lupoma may undergo necrosis and ulcera- 
 tion. The tendency to central necrosis which belongs to all processes 
 caused by the tubercle bacillus is relatively much less marked in 
 lupus than in the other forms of cutaneous tuberculosis. In some 
 cases, however, it may become more pronounced, giving rise to 
 restricted, rarely extensive or even enormous destruction of tissue; 
 the latter being characteristic of lupus exedens and vorax. The 
 features of lupus ulcerations will be discussed elsewhere in this book. 
 
 Tubercles of Leprosy. — The tubercles of leprosy, or lepromas, 
 originate either on erythematous pigmented spots or on the healthy 
 skin. They may appear separately and insidiously, or in crops 
 of numerous lesions, distributed with a certain symmetry on the 
 face ! Fig. 175), on the limbs, or in any region of the body. 
 
 Their usual appearance is as follows: Their size varies from 
 that of a hemp seed to that of a large almond; their shape is 
 hemispherical; their elevation is variable; the color is a dull pink, 
 or purplish, or brownish; their surface is smooth, always hairless, 
 sometimes oily or scaly; their consistence is firm at the onset, but 
 rather sottish and shrunken often after the lapse of some time. 
 
 Their principal properties are: (1) They are almost invariably 
 anesthetic toward pricks or burns, sometimes after a temporary 
 stage of hyperesthesia; (2) they are histologically composed of 
 collections of lepra cells, teeming with Hansen's bacilli. 
 
 Lepromas may become confluent in lobulated tumors, or they 
 may spread out in patches of variable extent, moderately promi- 
 nent, with a smooth or irregular surface interspersed with telan- 
 giectases, etc.; when they occur in patches they are designated as 
 leprous infiltrations or surface lepromas. 
 
 The duration of leprosy tubercles is usually very long, but follows 
 no rule. They may disappear through absorption, leaving a 
 white or pigmented cicatrix; this scar of leprosy infiltrations bears 
 the name of leprous morphea. 
 
 They may also undergo suppuration and ulceration; a primarily 
 superficial erosion increasing in depth and growing into an irregular 
 deeply excavated ulcer, with swollen margins, and a sanious floor, 
 sometimes becoming phagedenic and mutilating. 
 
TUBERCULO-ULCERATIVE DERMATOSES 259 
 
 Lepromata are characteristic of the tubercular or generalized 
 cutaneous form of leprosy and are also encountered in the mixed 
 form (Chapter XXVII). 
 
 Local treatment of leprosy tubercles yields very satisfactory 
 results. They may be treated with salves or plasters containing 
 strong reducing agents, or preferably by cauterization with the 
 galvanocautery, which leads to their prompt subsidence. [High- 
 frequency and radiotherapy are valuable measures, but it need 
 hardly be said that local treatment of a few nodules has little or 
 no effect on the course of the disease.] 
 
 Cutaneous Sarcoids or Lupoids. — The eruption, which was first 
 described by Boeck (1899) under the name of multiple benign cuta- 
 neous sarcoid, then as benign lupoid, manifests itself in the form of 
 lenticular or larger tubercles, which never become ulcerated. 
 
 General remarks on the sarcoids will be found further on and are 
 applicable to the lupoids, which in the main represent merely a 
 superficial dermic type of sarcoid, with lesions of small dimensions, 
 affecting more particularly the face and the upper limbs. 
 
 A distinction is made between two principal forms: 
 
 1. Disseminated Miliary Lupoid. — The eruption consists of hemi- 
 spherical elevations, the size of a millet seed to that of a large pea, 
 of a pinkish, then livid and finally brownish color, with a smooth 
 or very slightly scaly surface, of semi-solid consistence. On vitro- 
 pressure (compression under a glass slide) their- tissue is less trans- 
 parent than that of a lupoma and often seems to be made up of 
 separate granules. 
 
 The eruption is symmetrical and situated on the face, the 
 shoulders, the wrists (Fig. 90) and in general on the extensor sur- 
 face of the upper limbs; more rarely, lesions are noted on the scalp, 
 the back, or the lower limbs. It comes on in a few weeks, but 
 increases during months and years through growth and multipli- 
 cation of the lesions. In the course of time, the latter become 
 flattened, spreading out in nummular, sometimes marginated, spots 
 and finally become obliterated, leaving an atrophic often not very 
 noticeable cicatrix. The lesions are accordingly tubercles, in the 
 dermatological sense of the term. They never ulcerate, in notable 
 contradistinction to the lesions of acnitis. 
 
 The duration of the disease when left to itself is very variable, 
 from five to ten years or longer. It is observed much more fre- 
 quently in women, between the ages of fifteen and forty years, than 
 in men. The lymphatic glands are sometimes enlarged. In a 
 considerable number of the cases, the patients are evidently suffer- 
 ing from glandular or visceral tuberculosis. 
 
 The histology of lupoid tubercles is characteristic. The derma 
 is found to contain large lobulated or branching collections formed 
 
260 T UBERCLES A XD T UBERC ULO- ULCER A TI VE DERMA TOSES 
 
 chiefly of epithelioid cells, lymphocytes and a few rare giant cells; 
 these collections arc separated by connective-tissue strands, in 
 which practically no trace of inflammation is demonstrable. 
 
 Several modes of treatment have proved efficient, notably intra- 
 muscular injections of calomel, tuberculin injections and, according 
 to Boeck, arsenic medication; the best method of treatment actually 
 consists in combining aovarsenobejizol injections with tuberculin, 
 injected in very small doses. It goes without saying that the 
 hygienic condition of the patients must be supervised. 
 
 Fig. 90. — Disseminated miliary Lupoid. Multiple benign cutaneous sarcoid of 
 Boeck. 
 
 2. Nodular Lupoid. Nodular lupoid and lupoid in patches 
 (large nodular form of Boeck) is less well known. It consists of 
 hemispherical, purplish or brownish red elevations, the average 
 size of half a ha/el-nut, or in other cases of irregularly outlined 
 soft disks; these lesions, to the number of two or three up to ten 
 or more, occupy the forehead, the nose, the shoulders, the elbows, 
 the neighborhood of the knees, etc. 
 
 Confusion is possible with lupus, superficial tubercular syphilides, 
 
TUBERCULO-ULCERATIVE DERMATOSES 
 
 261 
 
 or leprosy infiltration. Their histology is related to that of lupus, 
 but inoculation of their tissue into guinea-pigs does not produce 
 tuberculosis. The tuberculin reaction is not constant. 
 
 I have thought that these two forms of lupoid which 1 have seen 
 coexisting with tuberculides or with glandular and pulmonary 
 tuberculosis, were tuberculides; this is very probable, but not 
 certain. Gorgen Schaumann (January, 1917) interprets the condi- 
 tion as a special benign infectious lymphogranuloma, of the same 
 character as lupus pernio. 
 
 Granuloma Annulare. — Undoubtedly identical with the ringed 
 eruption of Colcott Fox, the lichen annularis of Galloway, the 
 sarcoid tumors of Rasch, the nodular and circinate neoplasias of 
 Brocq, the granuloma annulare of Radciiffe Crocker is characterized 
 
 Fig. 91. — Granuloma annulare. The patient, a girl of three years, presented seven 
 other similar lesions upon the limbs. 
 
 by elevations or tubercles grouped in rings. At the onset, a firm, 
 smooth nodule the size of a small pea develops rather rapidly; by 
 eccentric growths, or by accession of other nodules, this becomes 
 transformed into a ring (Fig. 91); the color is a pale or dull pink; 
 there is absolute painlessness. The course is very slow, lasting 
 months or years ; the lesions never ulcerate and no scar is left after 
 healing. 
 
 This affection, which is rare, is observed in children or adults 
 of both sexes and occupies more particularly the hands, the finger- 
 joints and the wrists as well as the ankles, but also the elbows, 
 the knees, the buttocks, the nape of the neck, exceptionally the 
 face. As a rule, the lesions are few in number. Histology shows 
 a perivascular infiltration of lymphoid and epitheloid cells, deeply 
 situated in the corium; the epidermis is intact. 
 
202 TUBERCLES AND TUBERCULO-ULCERATIYE DERMATOSES 
 
 Granuloma annulare in many respects approximates the sarcoids 
 and the lupoids. Graham Little, in his very complete study of 
 the subject (1908) is inclined to consider it as a tuberculide. It is 
 treated with reducing plasters and the same general medication as 
 the sarcoids. 
 
 The erythema elevatum diuHnum of R. Crocker is probably merely 
 ;i disseminated or grouped but not annular variety of the same 
 affection. 
 
CHAPTER XIV. 
 NODES AND NODULES. 
 
 NODULAR DERMATOSES. 
 
 Under the name of nodes I comprise all circumscribed indurations 
 of the hypoderm, of whatever character. Nodes may attain the 
 size of an egg, or larger; nodules in my nomenclature are those 
 having the average size of a pea; nodosities are those having inter- 
 mediate dimensions. 
 
 Nodes constitute an elementary dermatological form, a symptom 
 comparable to an eruptive lesion. They play a part which must not 
 be underrated in the pathology of the skin. In my opinion, they 
 must of necessity figure in the morphology of the dermatoses. 
 
 The hyperderm is closely related to the corium by the continuity 
 of the connective-tissue and elastic fibers passing from one to the 
 other as well as by its blood and lymph vessels; furthermore, the 
 bulbs of the largest hairs and the glomeruli of the large sweat glands 
 are imbedded in the hypoderm. 
 
 On account of this inter-relation of tissues and vascular supply, 
 pathological processes are very apt to invade the two layers together 
 or successively, so that many pathological products are dermo- 
 hypodermic. 
 
 The group of nodes, formerly designated as phyma (French: 
 noudures; German: Knollen [or Knoten]), is usually subdivided in 
 France and classed in part under subcutaneous tubercles, in part 
 with gummas or even with tumors, etc. 
 
 It seems to me advantageous to devote a special chapter to their 
 discussion. 
 
 Nodes or nodosities may be subdivided according [1] to then- 
 volume, their consistence, their more or less distinct limitation; but 
 the diagnostic value of these features is insignificant; [2] according to 
 their purely hypodermic or dermo-hyper dermic seat, but this seat 
 may vary in the course of their development; [3] according to their 
 inflammatory, embolic, or neoplastic pathogenesis; this is not easy 
 to determine clinically. It is preferable to base a classification on 
 their course. 
 
 From this viewpoint, three forms can be distinguished: 
 
 A. Acute nodes and nodosities of sudden onset, are of ephemeral 
 or not very prolonged duration, from one to fifteen days, for instance, 
 and always terminate by resolution, without suppuration. 
 
264 NODES AND NODULES 
 
 In tliis acute form, the size of the products varies from that of a 
 pea to that of a hen's egg; their consistence is resistant or edematous; 
 their boundaries arc indistinct, in the sense of their occupying 
 simultaneously the subcutis and the cutis, with somewhat diffuse 
 outlines; the skin is usually congested on their surface; they are 
 painful to touch. Their abrupt appearance, in certain regions of 
 predilection, their distinctly inflammatory character, their tendency 
 to resolution are suggestive of their resulting from septic emboli of 
 low virulence. 
 
 Among the dermatoses in which acute nodes are met with, I shall 
 describe erythema nodosum and rheumatic nodosities. Giant urticaria 
 might likewise figure in this connection. 
 
 B. Subacute nodes and nodosities develop insidiously and last 
 from a fortnight to several months, or even a number of years. 
 Their volume usually varies from that of a hazel-nut to that of a 
 green almond; their consistence and the appearance of the skin are 
 modified according to their course of development; they are only 
 slightly painful. Their pathological anatomy shows them to be 
 derived from a subacute inflammatory process, frequently having a 
 venous or arterial point of origin and generally of specific character. 
 These cases accordingly represent syphilitic, tuberculous, leprous, 
 mycotic, or analogous newformations. 
 
 In this subacute form it is necessary to distinguish a group of 
 nodosities with a well-marked tendency to softening and ulceration: 
 these are designated as gummas. 1 
 
 Under the name of gummas will be accordingly discussed, first 
 in order: Syphilitic gummas, tuberculous gummas and finally mycotic 
 gummas, a more recent addition to our knowledge. 
 
 Another paragraph will be devoted to a discussion of subacute 
 non-gummous nodes. Their course and duration are very variable; 
 some of them never become softened and ulcerated, others excep- 
 tionally so. Under this heading I group: the nodular syph Hides, 
 the sarcoids, which are probably hypodermic tuberculides, and the 
 hypodermic lepromas. 
 
 C. If it were desirable to establish a group of chronic nodes or 
 nodosities, persisting indefinitely, one might do so at the expense 
 of the hypodermic tumors, which exist in all varieties of size and 
 consistence. Among such tumors as are sometimes capable of 
 giving rise to serious diagnostic difficulties, the following may be 
 mentioned. 
 
 Certain subcutaneous hard fibromas; many molluscoid nevi and 
 fibroma molluscum, such as those of Kecklinghausen's disease; a 
 
 1 The student's attention must be called to the fact that the French employ the 
 term Gomme (gumma) in a wider sense than is customary in English. The sig- 
 nificance of the term i« obvious from the text. 
 
ACUTE NODULAR DERMATOSES 265 
 
 considerable number of cysts; a few deep epitheliomas, cylindromas 
 and metastatic carcinomas; lipomas, myomas, calcareous tumors, 
 deep angiomas and many sarcomas (Chapter XXXI). 
 
 ACUTE NODULAR DERMATOSES. 
 
 Erythema Nodosum. — This affection is usually considered as a 
 simple variety of polymorphous erythema; but it certainly represents 
 the most individualized type of the disease. 
 
 Erythema nodosum is characterized by an eruption of nodosities 
 or nodes, dermo-hypodermic from the start, rounded or oval, 
 from the size of a bean to that of a large nut, of pinkish, carmine- 
 red or purple color, rather prominent, not very distinctly outlined, 
 painful to touch. They appear in a few hours, often with general 
 disturbances consisting of fever, malaise, prostration, rheumatoid 
 pains or actual arthritides; their number varies from a few lesions 
 to about thirty; they are found scattered, more rarely arranged in 
 groups on both legs, on the back of the feet, the thighs and sometimes 
 on the forearms, the arms and the buttocks. The bluish color of the 
 lesions, which often does not disappear on pressure, is due to inter- 
 stitial hemorrhage ; it undergoes the color variation of blood in course 
 of absorption and has given the name of contusiform dermatitis to 
 this affection. 
 
 The topographical distribution of the eruption, which is practically 
 always chiefly localized on the legs, its spontaneous onset, its course 
 and its duration which as a rule does not exceed two or three weeks, 
 permit it to be easily distinguished from traumatic contusions, 
 gummas, sarcomas, etc. 
 
 The etiology of this eruption agrees in indefiniteness with 
 that of polymorphous erythema; sometimes it becomes associated, 
 moreover, with other manifestations of this erythema. It may be 
 observed in the course of septicemias or toxicodermias, notably 
 in iodism. Its frequency has been commented upon in venereal 
 clinics, among patients suffering from gonorrhea or syphilis. 
 Mauriac and others, without sufficient reason, have actually admitted 
 the existence of a syphilitic erythema nodosum. Formerly, all 
 nodular erythemas were regarded as rheumatic. There is now a 
 tendency to hold tuberculosis especially responsible; in support of 
 this association, the practically general significance of which he had 
 asserted since 1907, Landouzy recently reported a case in which, 
 with his collaborators, he discovered a Koch's bacillus in a blood- 
 vessel and successfully tuberculized a guinea-pig with a portion of 
 the same nodule removed for biopsy. 
 
 The pathological anatomy of the nodes of erythema reveals an 
 acute inflammation of ordinary type, with extravasation of red 
 
206 NODES AND NODULES 
 
 corpuscles and a perivascular infiltration of round cells between 
 the adipose lobules; these lesions necessarily suggest an origin from 
 microbic emboli, placing them in the class of "phlebitides of the 
 cutaneous veins," studied by Philippson. Although it seems to be 
 an established fact that a transitory tubercular bacillemia is 
 responsible in a certain number of cases of nodular erythema, it 
 must not be overlooked that the immediate prognosis of this 
 affection is in the main always favorable and that the prognostic 
 significance of this blood infection must not be overrated. 
 
 The treatment is that of polymorphous erythema; rest is especially 
 necessary. 
 
 Rheumatic Nodosities. — The nodosities known under this name 
 must be approximated to erythema nodosum. Several types have 
 been described, all equally uncommon. In some arthritics suffering 
 from subacute rheumatism and intestinal dyspepsia , I have observed 
 the appearance of crops of nodules the size of a pea, subcutaneous 
 and without change of color of the skin, or intradermic and rose- 
 colored, of firm consistence, very painful on palpation. They were 
 situated especially around the knees, at the wrists, the shoulders, 
 etc., and lasted from twenty-four to forty-eight hours. 
 
 Fereol observed non-erythematous, very transitory, painless 
 nodosities, adherent to the skin, located especially on the forehead, 
 but always in small numbers. 
 
 The type pointed out by Meynet concerned deeply adherent, 
 hard, elastic, or edematous subcutaneous nodosities, without 
 reddening of the skin and slightly painful. Their volume varies from 
 that of a pea to that of a walnut. The crops consist of a fairly 
 considerable number of lesions, situated especially over bony pro- 
 tuberances, more particularly on the skull. Their duration is from 
 a few days to several weeks. Confusion must be guarded against 
 with gummas or with tumors. 
 
 Possibly these clinical forms are varieties of the same species, 
 but it is more probable that this syndrome expresses the result of 
 benign microbic embolisms of variable character. 
 
 The treatment consists in the administration of salicylates and 
 calcium salts. 
 
 GUMMAS. 
 
 Gummas are nodular pathological products, of infectious character 
 and subacute behavior, the course of which comprises four stages: 
 (1) Development; (2) softening; (3) ulceration and evacuation; 
 (4) repair. They are situated in the subcutis, where they originate 
 primarily around the blood and lymph vessels of this tissue; some- 
 times, they may reach it secondarily to a process of the same char- 
 acter developing in a subjacent organ, periosteum, gland, etc. 
 
GUMMAS 267 
 
 Many authors, who regard the essential feature of a gumma as 
 consisting of its special evolution, rather than of its hypodermic 
 seat, describe dermic gummas, developing in the cutis; this term is 
 interchangeable with tubercles. All that need be said is that 
 tubercles occasionally follow an evolution like that of gummas. 
 
 Hypodermic gummas, or true gummas, which are alone discussed 
 here, are syphilitic, tuberculous, or mycotic. 
 
 Syphilitic Gummas. — These represent typical lesions of this 
 group. The gumma begins as a limited induration of the hypoderm, 
 perceptible to the touch before it becomes visible; it gradually 
 enlarges, setting up around it an inflammatory reaction, first raises 
 and then invades the derma and finally almost invariably opens 
 externally through a crater-shaped ulceration. 
 
 In the developed stage, the nodule is of firm consistence, the size 
 of a pea to that of a walnut, indolent and movable. The mass 
 becomes pasty, then fluctuating, superficially and sometimes deeply 
 adherent; the skin becomes reddened and thinned. Up to this time, 
 absorption may occur without leaving a cicatrix, both spontaneously 
 and especially with the help of specific treatment. 
 
 More frequently the skin, raised and eroded from below, becomes 
 perforated on top of the protuberance; ulceration occurs and leads 
 to the escape of a turbid or purulent yellowish ropy [gummy] fluid. 
 The orifice enlarges, remaining round, of nummular dimensions; 
 its borders are thin, red, overhanging or perpendicular; the cavity 
 is deep, cup-shaped ; the floor is uneven, roughened, covered with a 
 yellowish-white substance, a sort of core, which is gradually elimi- 
 nated with the discharge; the base is of pasty consistence and tender 
 on pressure. The corresponding lymph nodes are not enlarged. 
 
 In the stage of retrogression, the granulating floor becomes raised 
 to the level of the borders where epidermatization begins, concen- 
 trically retracting and finally cicatrizing the ulcer after the infiltra- 
 tion has disappeared. The redness is replaced by a persistent 
 pigmentation which surrounds the white and smooth cicatrix. 
 
 This evolution extends over a space of time from fifteen to forty- 
 five days. 
 
 Syphilitic gummas are tertiary manifestations. Sometimes they 
 are precocious, appearing in the second half-year after infection, 
 and in this case they are called secondo-tertiary, according to Four- 
 nier's expression. Although especially frequent in the third and 
 fourth year, they may still occur after ten or fifteen years or 
 more. 
 
 They may be situated anywhere, rather commonly on the forehead, 
 on the scalp, at the lips, the genitals; they are often multiple or 
 develop in close succession to the number of from two to ten or 
 thereabouts, rarely more. 
 
2G8 NODES AND NODULES 
 
 Gummas of the tongue are rather rare. They appear in the form of 
 one or several hard intramuscular nodes the size of cherry pits on 
 hazel-nuts, studding the tongue and causing more inconvenience 
 than actual pain. They open as large ampullary or crater-shaped 
 ulcers, which heal leaving a very minute cicatrix. It is important 
 to distinguish them from the sclero-gummous ulcer*. 
 
 Gumma.'! of the palatine velum are rarely discovered before they 
 ulcerate. They give rise to merely slight inconvenience during a 
 week or two, then perforation of the palate suddenly occurs without 
 pain, often during a meal, manifesting itself by the return of liquids 
 through the nasal fossa 1 and by nasal speech. The gravity of this 
 complication is due to these functional disturbances, which are 
 persistent, cicatrization taking place without closing the perforation. 
 Recourse must be had to a [plastic] operation or a prosthetic appa- 
 ratus. Perforation of the palatine velum has long been considered 
 as a reliable stigma of syphilis or congenital syphilis. It has been 
 reported under other conditions, notably after scarlatina (?). 
 
 In the treatment of gummas, incision of the swelling has no 
 advantages and is only too often practised erroneously. Even 
 total excision, with careful suturing of the wound, would be 
 preferable; but syphilitic gummas, even after softening has occurred, 
 heal as a rule remarkedly well under specific treatment in all its 
 forms. The importance which was formerly attached to iodin 
 in the treatment of gummas, is undoubtedly due to the confusion 
 which prevailed between syphilitic gummas and those now known 
 to be of mycotic character. Very dilute local injections of soluble 
 mercurial salts are very efficient and may be utilized. 
 
 Tuberculous Gummas — also known as scrofulo-tubercular gummas, 
 or abroad as scrofuloderma — differ from the preceding by a few 
 details in their objective appearance and by their more gradual, less 
 continuous evolution. 
 
 The hypodermic nodosity which marks the onset of a tuberculous 
 gumma, is sometimes adherent from the start to the deep aspect 
 of the derma, which rather early presents a lavender, purplish, or 
 livid hue. Softening often begins superficially without affecting the 
 entire indurated mass; it may be absent or indefinitely delayed. 
 The fluid is sanious or even serous, turbid and mixed with blood. 
 Ulceration is frequently of an irregular configuration, with soft, 
 detached, purplish borders; the cavity is irregular, sinuous, some- 
 times sending fistulous tracts in different directions; it is lined with 
 gray or purplish filamentous detritus; its walls are softened or 
 locally indurated. 
 
 It is not uncommon for the multiple orifices of the same gumma, 
 or of neighboring gummas united in a gummous infiltration, to inter- 
 communicate by sinuous tracts which lead into the same cavity; 
 
GUMMAS 269 
 
 they are separated by bridges which may persist even after cica- 
 trization or may rupture as the result of erosion. 
 
 Tuberculous gummous ulcers accordingly often have sinuous and 
 ragged, undermined, pale or dark purple borders and an extremely 
 irregular floor. The discharge is very variable, distinctly purulent, 
 or serous and mixed with blood. The crusts possess corresponding 
 features. 
 
 These ulcers may invade the tendon sheaths, the joints and the 
 bones, from which they may also be derived. They are sometimes 
 transformed into fungoid tuberculosis or lupus. When they heal, 
 the cicatrix is usually irregular, often adherent in the depth of the 
 tissue, honey-combed with fibrous islands, dentated at the periphery 
 or undermined by fistulous tracts which pass under cicatricial 
 bands. The borders remain for a long time purplish, later becoming 
 pigmented. 
 
 The course is slow, with exacerbations and remissions, lasting 
 several months or sometimes years. 
 
 Scrofulo-tubercular gummas are frequently but not invariably 
 encountered in individuals whose general condition is unfavorable, 
 who suffer from visceral tuberculosis or especially from bony or 
 glandular tuberculosis. Children and youthful individuals are the 
 most susceptible. They number from one or two to about ten, 
 rarely more lesions presenting different stages; they occupy espe- 
 cially the extremities or the neck, sometimes the trunk, but often 
 the face. They are disseminated, more particularly in children 
 and youthful individuals; or they may show a regional distribu- 
 tion, especially when they are consecutive to a deep focus and, 
 in these cases, assume a lymphangitic type. 
 
 Tuberculous gummous lymphangitis, practically limited to the 
 extremities, originates from a lesion of the extremities, usually an 
 anatomical tubercle, tuberculosis verrucosa, spina ventosa, or 
 tuberculous caries of the bones. Arranged along the tract of the 
 lymphatics coming from this primary focus, a series of several 
 gummas begins to develop. A lymphatic strand may occasionally 
 be felt which unites these secondary foci. The corresponding 
 glands are usually indurated, sometimes suppurating or fistulized. 
 The duration of this trouble is indefinite; it may be prolonged until 
 death occurs from vertebral or visceral tuberculosis and from 
 cachexia. 
 
 The 'pathological anatomy of tuberculous gummas will be dis- 
 cussed elsewhere in this book. It will be seen that they usually 
 contain Koch's bacilli, although in moderate numbers, and that 
 their tissue causes tuberculosis in guinea-pigs inoculated with it. 
 However, clinically identical products are also met with whose 
 scrapings and sections contain no bacilli and whose inoculation into 
 
270 XODES AND NODULES 
 
 animals remains negative. This justifies the conclusion that the 
 clinical picture of scrofulo-tuberculous gumma may be produced by 
 hypodermic tuberculides. 
 
 The same picture may, moreover, be very closely simulated by 
 mycotic gummas; a thorough examination of the patient in regard 
 to his antecedents and the coexistence of internal tuberculous lesions, 
 is imperative for the diagnosis, although in many cases only the 
 laboratory findings are capable of confirming it. 
 
 Mycotic Gummas.- — Several infections through fungi may give 
 rise to genuine gummas. Sporotrichosis is the best known of these 
 and also the most common. Sporotrichotic gummas are sometimes 
 disseminated, sometimes lymphangitic and regionally distributed. 
 When disseminated, they may be found anywhere, in variable 
 number; they are indolent and develop in six to eight weeks. Firm 
 at first, then soft, they persist for more or less time in this condition, 
 then undergoing ulceration and evacuation. Their liquid contents 
 are at first viscid and gummous, later on purulent and thickened. 
 The ulcer may be covered by a crust, of ecthymatous appearance, or 
 again very deep, of rounded or irregular circumference, with under- 
 mined margins; sometimes, the floor is covered with granulation or 
 even large proliferations. This ulcer remains stationary a long time, 
 unless treatment intervenes (p. 605). 
 
 Sporotrichotic gummous lymphangitis consists of a series of 
 gummas developing in the centripetal lymphatic territory of the 
 initial focus (Fig. ISO), which may be dermic or hypodermic, or 
 bony, etc. A moniliform strand may connect the lesions. The 
 corresponding glands are often, but not always swollen and 
 enlarged. 
 
 Actinomycosis, in its primary cutaneous form, often has the 
 appearance of a hypodermic nodule, with a pinkish surface, hard 
 and practically painless, which softens at its center and ulcerates, 
 but from which a sanguinolent discharge escapes instead of pus; 
 the orifice remains fistulous. Neighboring nodules form and become 
 agglomerated with the first. The lymph glands remain intact. The 
 site of the lesions is most commonly the cervico-facial region (p. 599). 
 
 Some blastomycoses may give rise to gummas. This is particularly 
 true for the Buschke type, of which a few rare observations have 
 been recorded; it is a febrile infection, seriously interfering with 
 the general health. The origin, as a rule, is in the osseous system 
 whence there follow multiple disseminated gummas. [It would 
 seem probable that the point of entry for the organisms is an insig- 
 nificant cutaneous lesion, though a periosteal swelling may be the 
 first lesion to attract attention] (p. 603). 
 
 Mycetoma, or Madura foot, is a local mycosis characterized by 
 nodosities which become bullous on their surface, then softened and 
 
SUBACUTE NON-GUMMOUS NODES 271 
 
 ulcerated, accordingly representing true gummas; their agglomera- 
 tion may result in a monstrous deformity. 
 
 In "picm-bois," a Leishmaniosis, I have observed a sort of gumma 
 with a lymphangitic distribution. 
 
 For the diagnosis and treatment of these mycotic gummas, the 
 reader is referred to Chapter XXVIII. 
 
 [All the forms of cutaneous and subcutaneous tuberculosis are 
 relatively rare in America and blastomycosis seems to be more 
 common than sporotrichosis while the converse is true in France 
 and Germany.] 
 
 -SUBACUTE NON-GUMMOUS NODES. 
 
 Nodular Syphilides. — This name, as well as that of nodular 
 syphilitic phlebitis, is applied to hypodermic nodules which some- 
 times occur in the course of the secondary manifestations of severe 
 syphilis, associated in most cases with a profuse eruption of lentic- 
 ular papules. 
 
 The nodules are hard, distinctly outlined, movable under the skin 
 and on the underlying tissues, round, spindle-shaped or flattened, 
 the size of a large pea to that of an almond ; the skin on their surface 
 is normal or slightly reddened. They are painless when left alone, 
 but slightly tender on pressure. They are situated in variable 
 numbers, from a dozen to twenty at most, on the extremities, rarely 
 elsewhere. 
 
 Their size, their topography, their number, their free mobility, 
 and especially their course, serve to distinguish them from the 
 nodosities of erythema nodosum and syphilitic gummas. 
 
 In a case, observed with Civatte, the histological examination 
 enabled us to recognize distinctly the presence of a syphilitic 
 newformation (of the same type as the lenticular papule) which 
 developed in the wall of the subcutaneous veins giving rise to 
 thrombophlebitis. 
 
 The evolution of these nodular phlebitides is rather slow. They 
 have practically no tendency to undergo softening and ulceration, 
 but in the absence of treatment will persist for many weeks without 
 change. Under the influence of specific treatment, they very 
 promptly disappear. 
 
 Leprous Nodosities. — These products, known also as hypodermic 
 lepromas, often accompany the dermic leprous tubercles in moderate 
 number. In more interesting but less common cases, the nodosities 
 occur without tubercles, coincidently with erythemato-pigmentary 
 leprides. They can be detected only after careful search; as stated 
 by Leloir, they may be felt rather than seen, for they barely raise 
 the skin, 
 
272 NODES AXD XODULES 
 
 Hypodermic lepromas are situated chiefly on the buttocks, the 
 back, the external aspect of the extremities, on the face, and very 
 frequently on the ear-lobules, which appear as if stuffed with shot. 
 
 They are circumscribed, rounded or oval, the size of a pea to that 
 of a walnut, sometimes conglomerated, or they may be diffuse 
 (leprous infiltrations) in slightly raised, flat or uneven patches. 
 
 At the onset, the circumscribed nodules are firm and elastic and 
 at first movable; later on they become softened and adherent to the 
 skin, which turns red on the surface. Nodules and infiltrations 
 may ulcerate, thus becoming entitled to the name of leprous gummas 
 or gummxms infiltrations of leprosy; they contain a grumous pus very 
 rich in Hansen's bacilli. They often seem to persist indefinitely, 
 or they undergo absorption, leaving a sclerotic or even keloid 
 cicatrix, or no trace of their former presence. 
 
 SARCOIDS. 
 
 This term was devised by Kaposi to designate newformations 
 resembling sarcoma. Boeck (of Christiania) described under the 
 name of multiple benign cutaneous sarcoids, eruptions of tubercles 
 resembling lupus; more recently, he called them lupoids. Other 
 newformations have also been designated under the name of 
 sarcoids. In a report to the XVI International Medical Congress 
 (1909) I pointed out that until the etiology and real character of 
 these new-formations are elucidated, the denomination sarcoids is 
 indispensable. 
 
 It designates a group of connective-tissue newgrowths which 
 manifest themselves clinically in the form of nodes, nodosities, 
 nodules or tubercles, usually multiple, painless, of slow or even 
 chronic, but not unlimited development. They are benign in the 
 sense that they have no tendency toward softening and ulceration, 
 do not recur locally after removal, do not give rise to visceral 
 metastases and do not notably affect the general health. They are 
 subject to retrogression, either spontaneously or under the influence 
 of arsenical agents, mercury, tuberculin, etc. 
 
 Anatomically, these sarcoids are made up of cellular collections 
 or infiltrations often of a tuberculoid structure, insinuated into the 
 framework of the derma or the hypoderm — which distinguishes 
 them from the sarcomas, whose constituents are arranged in coherent 
 and homogeneous masses. 
 
 The following pathological types come under this definition: 
 
 1. Cutaneous Sarcoids. — Cutaneous sarcoids of Boeck, or lupoids. 
 Their intradermic seat and their small dimensions have led me to 
 group them among the tubercles (p. 2o9). 
 
SARCOIDS 273 
 
 2. Hypodermic Sarcoids. — As described by me with Roussy (1904 
 to 1906), these are painless subacute or chronic newformations, 
 the size of a bean to that of a walnut, or larger; they often become 
 confluent in large uneven patches and nodular strands. The skin 
 over them is raised, of normal, lavender, or dull red color. At 
 first sight, they might be mistaken for tumors, but they have no 
 unlimited extension. They are observed in adults of both sexes; 
 their duration is indefinite. 
 
 These sarcoids are generally grouped in certain regions, and have 
 a tendency to a symmetrical arrangement. I know of two seats 
 of predilection: on the one hand, the costal region, the flanks, and 
 the scapular region, on the other, the anterior aspect of the thighs, 
 and the lower portion of the abdomen. However, they are also met 
 with elsewhere, on the arms, the forearms and even on the scalp. 
 This type is relatively rare. 
 
 These sarcoids must not be confused with tumors of various kinds 
 of the thoracic wall, nor with axillary, cervical or other adenop- 
 athies. On the thighs they may be very closely simulated by 
 nodosities due to the injection of camphorated oil, or other hypo- 
 dermic injections, which sometimes persist indefinitely. The 
 appearance of genuine sarcoids, however, seems to be absolutely 
 spontaneous. The paraffinomas will be mentioned further on. 
 
 3. Disseminated Nodular Sarcoids. — These are nodes or nodules 
 which develop successively in crops and are scattered particularly 
 over the extensor surface of the extremities more or less symmet- 
 rically, but also on the trunk and sometimes even on the face. 
 They usually number from about ten to thirty, but I have counted 
 over one hundred and fifty in one case (Fig. 92). The skin over 
 them is of normal color, or pinkish, or brownish-purplish, raised or 
 on the contrary slightly depressed and on pressure may present the 
 appearance of orange-peel. Their consistence is very hard, or some- 
 what doughy; with rare exceptions they are painless. Very rarely, 
 some may become eroded on their surface and covered with a crust. 
 They are observed at all ages, in both sexes, and are not very 
 uncommon [in France]. They may disappear spontaneously. 
 
 These disseminated sarcoids possess a great analogy with scrof ulo- 
 tuberculous gummas in the firm stage ; they differ f rOm them in that 
 they do not soften and ulcerate; but these two pathological types 
 may exist together. 
 
 They also possess such marked analogies with the erythema 
 induratum of Bazin that I have thought these two affections might 
 be identical; erythema induratum would then be merely a particular 
 form, an objective appearance of disseminated sarcoid. It is, 
 however, entitled to separate mention. 
 
 18 
 
274 
 
 NODES AND XODULES 
 
 4. Erythema Induratum of Bazin. — Under the name of crytheme 
 indure des scrofuleux, Bazin had described more or less deeply 
 indurated and imperfectly outlined, pinkish, red orpnrplish patches, 
 which are observed in youthful individuals, especially young girls, 
 almost invariably occupying the outer and lower portion of the legs; 
 they may also be observed on the thighs, on the upper limbs, and 
 even on the forehead. Their course is subacute, with congestive 
 exacerbations accompanied by throbbing pains; periods of retro- 
 gression occur under the influence of rest. 
 
 92. — Disseminated nodular sareoids on the 
 
 aged forty-five years. 
 
 lower abdomen of 
 
 English authors, Colcott Fox and especially -I. Hutchinson, have 
 shown that Bazin's disease, as they call it, not infrequently gives 
 rise to sluggish and obstinate ulcers (Fig. 102); this is the English 
 type, or Hutchinson's type, which in this respect distinctly differs 
 from the sarcoids and approximates the tuberculous infiltrations. 
 
 The histological structure of the various sarcoids referred to above 
 is not uniform. The structure of the cutaneous sarcoid of Boeck, 
 or lupoid, is entirely distinct. The hypodermic sarcoids of the 
 1 )arier-Roussy type are to the highest degree tuberculoi 1 in structure 
 (Fig. 93), perfect tubercles [in the pathological sense] being found 
 
SARCOIDS 
 
 275 
 
 in addition to the ordinary lesions due to reaction of the adipose 
 tissue, known since Flemming under the name of " Wucheratrophie" 
 (proliferative atrophy). The disseminated sarcoids have either 
 an analogous structure, or that of inflammatory newformations; 
 the whole gamut of lesions may be met with from erythema nodosum 
 to the most characteristic tuberculous gummas. In erythema 
 nodosum, the infiltration is also more or less ordinary, or else tuber- 
 culoid with partial necrosis. Thibierge and Ravaut, Mantegazze 
 and Guibert emphasize the vascular lesions, which I was always 
 able to demonstrate. 
 
 Fig. 93. — Histology of hypodermic sarcoids. Tuberculoid focus at the 
 periphery of a lobulated nodosity of the thoracic region, a, giant cell; b, zone of 
 epithelioid cells; c, c, zone of lymphocytes; d, fibrous tissues surrounding the nodosity ; 
 e, sclerosis of the adipose tissue; g, collection of epithelioid cells belonging to a neigh- 
 boring tubercle. X 130. 
 
 The nature of the sarcoids is obviously infectious and the patho- 
 genic mechanism of their origin is undoubtedly through embolism . 
 But their etiological connection with Koch's bacillus, which would 
 make them tuberculoses or tuberculides, has not been established, 
 at least not for all types. Histology, as is now known, does not 
 settle the question, for the tubercle is by no means characteristic 
 of the bacillary infection, but may occur in the mycoses, in syphilis, 
 leprosy, etc. Inversely, the absence of tubercles, according to 
 numerous recent contributions in no way excludes the presence of 
 Koch's bacillus. 
 
 As regards erythema induratum, its tuberculous nature may be 
 said to be an established fact based on its common coincidence with 
 visceral, bony, glandular, or cutaneous tuberculosis; or with papulo- 
 
276 NODES AND NODULES 
 
 neurotic tuberculides and lichen scrofulosorum ; and from its reaction 
 to tuberculin. Still more direct proofs have been furnished; its 
 tissue infects inoculated guinea-pigs with tuberculosis (Thibierge 
 and Ravaut, Carle) and, in a few cases, the bacillus has been 
 demonstrated therein (Philippson, Jadassohn). 
 
 Notwithstanding coincidences and transition forms, no such 
 definite conclusions can be formulated in regard to the other types. 
 It is still desirable, in cases coming under observation, to look for 
 the Wassermann reaction, which is negative as a rule, and for the 
 tuberculin reaction which is generally positive, as well as to carry 
 out the necessary laboratory tests. The solution of this problem 
 belongs to the future. 
 
 The treatment of sarcoids with arsenic has been vaunted as 
 well-nigh specific; arsenobenzol is sometimes remarkably successful 
 (Ravaut); I have obtained excellent results from calomel injec- 
 tions; at the same time as Thibierge, I became impressed with 
 the rapid efficacy of tuberculin injections in very minute doses, 
 especially in erythema induratum; as a rule, a combined medication 
 with novarsenobenzol and tuberculin gives the best results. Rest 
 and good general hygiene are imperative. In spite of treatment, 
 recurrences are to be anticipated. 
 
 The term paraffinoma has been applied to hypodermic lesions 
 which are often caused by injections of paraffin; in certain respects, 
 these may be compared with artificial or induced sarcoids. About 
 fifteen years ago vaselin injections and then injections of paraffin at 
 a melting point of 65° or .V)° were recommended for the correction 
 of various congenital or acquired deformities, saddle-nose, mis- 
 shapen ears, atrophic rhinitis with ozena, bad sears, fistulas, and 
 even for the esthetic improvement of the face, the base of the neck 
 or the female breast. 
 
 These injections are not devoid of danger. After a few years, a 
 progressive swelling with a coppery redness and very painful tension 
 may make its appearance at the injected points. Its cause is easily 
 recognized from the site and the statements of the patient. 
 
 Histological examination shows a diffuse, nodular, chronic inflam- 
 mation, with microscopical abscisses and giant cells, caused by the 
 paraffin which has spread between the tissue-meshes and hollowed 
 out cavities lined with endothelium. Injections of vaselin or cam- 
 phorated oil sometimes produce analogous lesions. Massage, 
 electrolysis and aspiration are usually inefficient and it is necessarv 
 to resort to surgical ablation. 
 
CHAPTER XV. 
 
 ULCERATIONS, ULCERATIVE DERMATOSES AND 
 CUTANEOUS GANGRENES. 
 
 Ulcerations of the skin are losses of substance due to a patho- 
 logical process of molecular destruction or of gangrene, in contra- 
 distinction to wounds, which are directly produced by a trauma. 
 
 The term ulcer is reserved more particularly for chronic ulcera- 
 tions with a marked tendency to persist a long time or indefinitely. 
 
 Cutaneous gangrene is the mortification or necrosis of a more or 
 less extensive portion of the tissues. 
 
 I shall first discuss ulcerations in general and the ulcerative 
 process; then the ulcerative dermatoses; finally, gangrene. 
 
 ULCERATION IN GENERAL. 
 
 Clinical Features. — The various ulcerations are differentiated by 
 numerous features, which must be kept in mind for the diagnosis. 
 
 1. The variable depth of the loss of substance permits a distinc- 
 tion between : excoriations, which are superficial, involving only the 
 epidermis and often resulting from a blister, a superficial pustule, 
 or a vesicular process; they heal without a scar, leaving a simple 
 pigmentary macule; and true or dermic ulcerations, which encroach 
 upon or destroy the derma and are necessarily followed by scar- 
 formation. 
 
 2. The extent of the ulcerations is rarely of much importance; it 
 is useful to know, however, that certain varieties never acquire large 
 dimensions, whereas others on the contrary may be of almost 
 indefinite extent. 
 
 3. The configuration is geometrical or irregular, rounded, oval, 
 polycyclic, reniform, circinate, etc. 
 
 4. The borders may be either sharp or imperfectly outlined, 
 perpendicular, detached or overhanging, sloping, raised or flat, 
 slanting, everted, fissured, etc. 
 
 5. The floor may be level or uneven, granular, papillomatous, 
 "worm-eaten," sinuous, crateriform, raised, etc. 
 
 6. The color of the floor of ulcerations is red, purplish, grayish or 
 yellowish. 
 
 7. The discharge is serous, purulent, hemorrhagic or sanious, 
 and more or less profuse. 
 
278 
 
 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 8. The crusts which resull from the drying of the exudate present 
 a variable appearance. Ostreaceous crusts, which arc thicker in 
 the center and apparently made up of heaped up disks of dimin- 
 ishing size, deserve special mention. They are characteristic of 
 the lesion described as rupia by older writers (Fig. 94). Their 
 occurrence is noted on ulcerations which increase intermittently, 
 such as certain syphilides, more rarely in ecthyma. 
 
 9. The base of the ulcerations is sometime- soft, edematous, in 
 other cases infiltrated and more or less indurated. 
 
 10. The periphery varies in color, consistence, condition of its 
 surface, etc. 
 
 11. Tenderness, spontaneous or induced, or on the contrary 
 anesthesia, are peculiar to certain form-. 
 
 
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 streaceous crusts in a case of ulcerative secondary syphilides. Syphilitic 
 rupia of old authors. 
 
 12. The condition of the corresponding glands deserves attention; 
 so also 13) the site and (14) the course of the ulcerations. 
 
 Among these various features, those relating to the borders, the 
 configuration, the base and the periphery possess the greatest value. 
 They may afford information, to a certain degree at least, as to the 
 process involved or show if the ulceration has occurred in healthy 
 >kin or at the expense of an infiltration or a tumor. 
 
 As To the topographical seat of the ulcerations, this is one of the 
 signs mosl relied upon by the practitioner, often subconsciously, 
 l.ut not without reason. The fact that the lesions are situated, for 
 example, on the face, the genitals, the legs, or the extremities, in 
 itself supplies a valuable indication, often limiting the field of the 
 diagnostic possibilities. The only feature of ulcerations, however, 
 which in my opinion can be utilized for a rational classification, is 
 represented by their course. 
 
ULCERATION IN GENERAL 279 
 
 Pathogenesis. — The mode of formation of ulcerations is variable. 
 Exceptionally, they result from mortification en masse of a more 
 or less extensive portion of the tissues; this is what occurs in 
 the gangrenous dermatoses. 
 
 Sometimes a dermic ulceration is derived from deep extension 
 of an excoriation; or it may apparently develop in healthy skin; 
 most commonly it is the result of disintegration or partial necrosis 
 of an infiltration (tuberculous syphilitic, leprous, etc.), or of a tumor 
 (epithelioma, mycosis fungoides, etc.). 
 
 In all these cases, the loss of substance results from the necrosis 
 or necrobiosis of the cellular elements and of the tissue framework, 
 followed by their molecular disintegration. 
 
 Without entering into unnecessary details, it is sufficient to 
 emphasize that the conditions of the ulcerative process, as far as 
 they are known, may be of two orders. One of these conditions 
 concerns the germ or virus which may at the same time possess a 
 toxic, necrotizing and digestive or lytic property and be able for a 
 long time to resist the defensive measures of the organism ; as is the 
 case in soft chancre and very probably in phagedenism. 
 
 The other condition refers to the soil and consists of an imperfect 
 blood supply, due to preexisting regional vascular lesions (varicosi- 
 ties, etc.), or to the effect of the pathological process itself (tubercu- 
 losis, syphilis). Sometimes a general metabolic disturbance may 
 be held responsible [diabetes, etc.]. 
 
 Disturbances of innervation undoubtedly also play a part, not 
 yet fully elucidated but proved by the so-called trophic ulcers, 
 such as malum perforans, ulcers of nerve-leprosy, etc. 
 
 Different pathogenic factors are often combined. 
 
 Etiology. — In a general way it may be stated that all agents 
 injurious to the tissues may, through their prolonged activity, give 
 rise to and maintain ulcerations. They are divided into mechanical, 
 physical, chemical and microbic agents. 
 
 Repeated traumatisms, by tools, shoes, bandages, or badly fitting 
 apparatus, produce ulcerations. Their seat and form are often 
 suggestive. A particular instance of these traumatic ulcers is 
 furnished by the setons or issues, which our forefathers believed 
 it advisable to establish by means of simple or epispastic agents. 
 
 As regards the induced [or artificial] ulcers which are observed on 
 self-mutilators and malingerers and which were formerly referred 
 to an assumed hysterical pemphigus, these are outside of any possible 
 general description, in view of the variety of means employed and 
 their results. 
 
 Crevices, rhagades, fissures or cracks are usually grouped among 
 ulcerations, although not resulting from a loss of substance; they 
 are rather linear wounds of traumatic origin in a dermic tissue 
 
280 ULCERATIONS AM) ULCERATIVE DERMATOSES 
 
 the elasticity of which may. however, have beeB impaired by a 
 preceding inflammatory process. 
 
 They are met with on the extremities, mi the hands and feet, as 
 complications of a hyperkeratosis, or at the circumference of the 
 aatural orifice-, at the lips,, especially in scrofulous children, at the 
 nipples of wet-nurses, very frequently at the anus, on the prepuce of 
 diabetics, etc. Under the influence of movements of extension, the 
 keratotic or macerated, sometimes even eczematized epidermis 
 cracks and the lesion reaches down to the cutis. The borders of 
 the crevices are perpendicular, the floor is bright red, sometimes 
 bleeding; pain is often very severe; healing may take place without 
 [visible] scars. 
 
 Fig. 95. — Tubular epithelioma in the form of ulcus terebrans 
 
 The pain of cracks or crevices is relieved by local anesthetics, 
 cocain and analogous remedies; superficial cauterizations with 
 [a 5 per cent, solution of] silver nitrate may sometimes prove useful; 
 it often suffices to apply either poultices or emollient dressings, or 
 pastes or varnishes containing keratoplasty or keratolytic agents, 
 according to the requirements of the case. 
 
 Among the ulcerations resulting from physical agents, those 
 due to burn-, frost-bites, .'-rays, etc. (Chapter XXIII) may be 
 mentioned. 
 
 Various toxic agents produce pustulo-ulcerative or primarily 
 ulcerative lesions, either through ingestion, or more often as the 
 result of externa] application. As an example may be mentioned the 
 occupational arsenical ulcerations, occurring especially on the hands 
 
ACUTE ULCERATIONS 281 
 
 and sometimes on the face and the genitals of laborers who handle 
 arsenic or its compounds [such as Paris green]. 
 
 The principal factors of ulcerations are microorganisms, which 
 are concerned either exclusively and primarily, or in cooperation 
 with other causes. This matter will be referred to again in connec- 
 tion with the ulcerative syndromes in particular. 
 
 As regards the ulcerations of tumors, their objective features and 
 their course are too closely connected with those of the causative 
 neoplasms to render a separate description advisable. It is neces- 
 sary to state, however, that in some exceptional cases, the ulceration 
 so markedly exceeds the neoplastic process that the latter may 
 remain unrecognized. This rarely happens in the various sarcomas, 
 in mycosis fungoides or in lobulated epithelioma, but is on the con- 
 trary very common in tubular epithelioma (Fig. 95), which was 
 and still is described in some of its clinical forms under the name 
 of rodent ulcer or ulcus epitheliomatosum terebrans. 
 
 Ulcerative Dermatoses. — Based especially upon their course, I 
 distinguish between the following groups: 
 
 A. Acute Ulcerative Dermatoses. — They develop rapidly in healthy 
 skin, never assume large dimensions, suppurate frankly and freely 
 and are usually due to an external local infection. Soft chancre is 
 typical of these dermatoses. 
 
 B. Subacute Ulcerative Dermatoses. — They are derived from one 
 of the great subacute infections, more particularly syphilis, tuber- 
 culosis and leprosy. The ulceration takes place at the expense of a 
 preliminary newformation. 
 
 C. Phagedenic Ulcers. — This name is applied to ulcers of rapid 
 spread and great chronicity. 
 
 D. Chronic Ulcerations, or True Ulcers. — Their pathogenesis is apt 
 to be complicated. 
 
 E. Ulcerations of Mucous Membranes. — The excoriations and ulcer- 
 ations of mucous membranes are discussed in a separate paragraph, 
 because it seemed to me convenient for the reader to find in one 
 place important data on the diagnosis of lesions of the mouth and 
 of the genital organs; these data will practically supplement what 
 has already been stated on this subject in Chapter XL 
 
 ACUTE ULCERATIONS. 
 
 Soft Chancre. — Soft chancre (ulcus molle) or chancroid, which will 
 be described elsewhere from the nosographical viewpoint, develops 
 very rapidly, and at the end of two or three days possesses its 
 typical features. 
 
 It is a round or oval, relatively deep ulceration, the size of a pin- 
 head, a lentil, a dime, or rarely larger. Its borders are perpendicular, 
 
282 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 undermined or slightly detached; often they are cracked or fissured. 
 The floor is of a creamy yellow or yellowish gray, irregular, "worm- 
 eaten." The base is soft, sometimes doughy, but not parchment- 
 like or cartilaginous. The circumference is red, slightly swollen. 
 
 Soft chancre lias an abundant, distinctly purulent discharge. 
 It is rather painful on touch or when the skin of the region is 
 rubbed in moving. It is rarely single; as a rule, several are found, 
 originating from the same contagion or from successive auto- 
 inoculations. This was humorously expressed by Ivicord when he 
 said that the soft chancre is a family man and lives surrounded by 
 his children. In some cases, in persons suffering from the itch, for 
 instance, over a hundred soft chancres have been counted on the 
 same subject. 
 
 The corresponding lymph glands are usually swollen and painful, 
 one among them often greatly preponderating. This glandular 
 swelling has a marked tendency to suppurate and discharge, under- 
 going transformation into an ulcer representing the so-called chan- 
 croid bubo of French writers. 
 
 Soft chancres are situated in the genital region in the vast majority 
 of cases. They may occupy any point of this region; in men, the 
 prepuce, the sulcus coronarius, the frenum, which is very often 
 perforated, then divided, or the skin of the penis are involved; in 
 women, the vestibule, the labia minora, the fourchette, the pre- 
 putium clitoridis and frequently the anus. In the last-named 
 localization, which may result from auto-inoculation, the chancre 
 frequently appears double, the two folds of the ulcerated surface 
 resting against one another, while its swollen lower border produces 
 a protuberance resembling a condyloma. 
 
 The neighboring regions — intergluteal fold, internal aspect of the 
 thighs, pubis, etc. — are affected in a considerable number of cases. 
 
 Extragenital Soft Chancres are rare. They may be observed on 
 the fingers or on the hand (Fig. 90), where they are often misinter- 
 preted; also on the face, although the existence of cephalic soft 
 chancre was formerly denied. 
 
 The diagnosis is often easy, on account of the distinct objective 
 features, the topography, the usual multiplicity, the rapid course of 
 the ulcerations and the painful glandular swelling. 
 
 In doubtful cases, absolute certainty can be secured by means of 
 two procedures: (1) Demonstration of the specific streptobacillus 
 in the pus; (2) experimental auto-inoculation, which is valuable in 
 that it provides a conclusive answer within forty-eight hours. 
 This inoculation should be made in the deltoid region; as soon as 
 it has been recognized as positive, the focus must promptly be 
 destroyed by means of the thermocautery. In all doubtful cases, 
 such as will be described, the employment of these two diagnostic 
 
ACUTE ULCERATIONS 
 
 283 
 
 procedures, at least of inoculation, is imperative, as the treatment 
 of soft chancre demands much more energetic measures than are 
 necessary in the case of the ulcerations which mav simulate it. 
 
 Fig. 96. — Soft chancre of the back of the hand. 
 
 Other Acute Ulcerations. — Mixed Chancre. — The mixed chancre 
 of Rollett is not common, but has been observed with some frequency 
 during the war. It results from inoculation at the same point with 
 the bacillus of soft chancre and the spirochete of syphilis. When 
 this inoculation has been simultaneous, a soft chancre develops first ; 
 at the end of two to four weeks, the incubation period of syphilis, 
 the base of this chancre becomes distinctly indurated, its surface is 
 modified to resemble that of a primary lesion and a generalized 
 adenopathy develops. The demonstration of the spirochetes in 
 such cases is very difficult and the diagnosis usually depends on the 
 appearance of a positive Wassermann reaction. 
 
 When the inoculation is successive, namely when an indurated 
 chancre becomes infected with virus of soft chancre, which is uncom- 
 mon, the transformation occurs in the opposite direction. One 
 must avoid the frequently committed error of applying the name 
 mixed chancre to a soft chancre occurring in an already syphilitic 
 subject, who therefore presents from the start a positive Wassermann 
 reaction. The treatment must of course be both local and general. 
 
 Ulcerative Syphilitic Chancre. — The primary lesion of syphilis is, 
 as a rule, simply erosive and seems to be an insignificant " sore." 
 
 In exceptional cases, in weakened or exhausted, alcoholic or 
 diabetic subjects, in localizations predisposed to irritation and super- 
 added infection, indurated chancre becomes ulcerative, deeply 
 invading the derma and burrowing both superficially and deeply. 
 A "chancre terebrans" may perforate the prepuce or even the urethra 
 in men, one of the labia minora in women, etc. The ulcer is painful ; 
 its irritable, proliferating, granular floor resembles that of a soft 
 
284 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 chancre. The induration of the base, however, is often verymarked; 
 the purulent discharge is less profuse than in soft chancre, auto- 
 inoculation docs not occur and generalized glandular swelling 
 supervenes. 
 
 Ulcerative Secondary Syphilides. 'I heir course may be very rapid, 
 or subacute. I shall have more to say concerning them later. 
 
 Ulcerated Herpes. Although herpes is primarily vesicular and 
 ordinarily gives rise only to very superficial erosions, these may 
 become deep and suppurate under certain conditions of territory or 
 of improper treatment. 
 
 The differential diagnosis from soft chancre, often rather difficult, 
 pests in such cases on the polycj clic arrangement of the lesions, their 
 simultaneous appearance, the persistence of non-infected herpetic 
 elements in the vicinity and especially on the negative outcome of 
 experimental auto-inoculation on the arm. 
 
 Ecthyma. This consists of an at first bullous or pustular, secon- 
 darily ulcerative lesion. It affects especially the lower limbs, some- 
 times the trunk and has no predilection for the genital region. 
 The ulcers have gently sloping, not perpendicular borders. 
 
 In all the cases mentioned, except that of mixed chancre, micro- 
 scopical examination of the pus in smears shows the absence of the 
 streptobacillus; inoculation on the arm produces a superficial 
 impet igo-pustule, without involvement of the cutis and healing of its 
 own accord in at most three or four days. 
 
 SUBACUTE ULCERATIONS. 
 
 Syphilis As a rule, the secondary lesions undergo resolution, the 
 tertiary lesions alone being destructive and having a tendency to 
 ulcerate. 
 
 Sometimes, however, beginning with the first eruption, the papulo- 
 crusted lesions ulcerate under the brownish or grayish crust which 
 covers them; at the same time, more or less extensive and destruc- 
 tive ulcerations appear on the mucosa'. These eases are described 
 ;i- syphilis maligna precox. Weakened, undernourished or alcoholic 
 individuals are predisposed to it; a special property of the germ has 
 often been held responsible and tropical syphilis is of bad repute 
 in this respect. However, this special course has also been noted in 
 robust individuals who were infected by a syphilis of ordinary 
 behavior. So much is certain that the spirochetes are usually rare 
 in the malignant syphilides, although inoculation into monkeys 
 may yield a positive result. 
 
 Ulcerative secondary syphilides constitute an irregularly scattered 
 eruption of ulcerations which develop and enlarge rapidly; they 
 have a round or more often oval form, perpendicular purplish 
 
SUBACUTE ULCERATIONS 
 
 285 
 
 borders, a cupola-shaped floor, filled with sanguinolent pus, and a 
 soft base. They are only slightly painful, except in certain 
 localities. 
 
 Their peripheral extension and the dessication of the pus which 
 they secrete, sometimes give rise to ostreaceous crusts, thicker in 
 their center; this picture was formerly designated under the name 
 of syphilitic rwpia (Fig. 94). 
 
 Fig. 97. — Serpiginous tuberculo-gummous syphilides. 
 
 Discrete or profuse, sometimes even confluent in places, the 
 secondary ulcerative syphilides sometimes co-exist with deep ulcer- 
 ations of the mucous membranes and do not readily heal; they 
 leave honeycombed dyschromic, sometimes mutilating cicatrices 
 which constitute significant stigmata. They are usually associated 
 with rapid emaciation, considerable cachexia, fever, albuminuria 
 and pulmonary or digestive complications and may lead to death. 
 
286 
 
 VLCERATIOXS AM) riJ'Eh'ATIYE DERMATOSES 
 
 Malignant syphilis had been observed to be often rather resistant 
 to mercury and iodide treatment, and in addition arsenic medication, 
 injections of hypertonic sera, a strict hygiene and careful local 
 dressings were recommended. The introduction of the arseno- 
 benzols has improved the prognosisof this form of the disease; their 
 efficacy is remarkable and rapid; it is recommended to combine 
 their action with that of injections of soluble mercury or calomel. 
 
 Ulcerative tertiary syphilides are derived from tubercles, gumma, 
 gummous infiltration, or sclerosing gumma. All of these, in contra- 
 distinction to the ulcerative manifestations of the secondary period, 
 are generally localized or regional. Five principal types are dis- 
 tinguished: 
 
 it 
 
 V 
 
 , 
 
 FlG. 98. — A typical syphilitic ulceration on the thorax near the right axilla. 
 
 1. Tvherculo-ulcerativb, also known as tuberculo-gummous xii}>hi- 
 lides (Fig. ( .I7) consist of rather large dermic tubercles, from the 
 size of a pea to that of a hazel-nut, of firm consistence, but almost 
 invariably terminating in ulcerative disintegration. Usually grouped 
 in clusters, crescents, etc., these ulcerations develop excentrically 
 and become arranged in serpiginous patches or areas of a highly 
 characteristic appearance. These areas are honeycombed scars, 
 checkered with whitish, purplish or earthy hues; the polycyclic 
 border presents, sometimes only on one side, rows of deep ulcera- 
 tions, round or in their turn polycyclic and punched-out, discharg- 
 ing a livid pus, or covered with thick, hard, adherent, sometimes 
 ostreaceous crusts of a greenish-black color. The double polycyclic 
 character of the patch and of its constituent ulcerations possesses 
 marked diagnostic value. 
 
 '_!. Syphilitic ulcerations which may be called atypical have a 
 less characteristic appearance. As a rule it cannot be determined 
 whether or not they have begun under the form of tubercles; at 
 
SUBACUTE ULCERATIONS 
 
 287 
 
 any rate, none are found at the circumference of the resulting lesion. 
 This is usually a single ulceration, having the shape of an oval, a 
 bean, an ear, etc., with regular margins describing fairly large 
 curves, often with a moderately hard, raised border with an uneven 
 rather shallow floor, sometimes cicatricial in the center (Fig. 98). 
 Their distinct polycyclic contours, the indurated border, the 
 parchment-like induration of their base, which, however, is not 
 always easily demonstrable, the examination by biopsy, if necessary, 
 serve to differentiate these tertiary ulcers from atypical tuberculous 
 ulcers which will be discussed further on ; they are much less deeply 
 evacuated than gummous ulcers; their shape is more regular and 
 their progress is decidedly more rapid than that of an epithelioma. 
 
 Fig. 99. — Syphilitic gummous 
 ulceration. 
 
 Fig. 100. — Syphilitic gummous in- 
 filtration, deeply ulcerated in places. 
 The woman from whom this photograph 
 is derived suffered from lesions of the 
 same kind on the thighs, the thorax and 
 the neck. Cure in two months through 
 calomel injections. 
 
 3. Syphilitic gummous ulceration is a deeper lesion, with rounded 
 or kidney-shaped contours, and loose, soft or edematous borders 
 (Fig. 99). It results from the disintegration and evacuation of a 
 hypodermic node. 
 
288 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 -i. Ulcerated gummous infiltration is of very variable extent, 
 depth and configuration. It may extend to the tendons, the vessels, 
 the periosteum, even the hones, causing very serious mutilations 
 (Fig. 100). 
 
 ,"). Sclero-gummous ulcerations arc those which originate in tertiary 
 syphilitic, sclerotic or scar-tissue. They are observed especially 
 on the tongue, though sometimes on the legs or in hypertrophic 
 syphilomas. They result from a focal or a superficial necrosis, dry 
 and caseous at first, later softening. Their abrupt onset, their 
 irregular, sometimes angular form, the woody induration of their 
 base, the slowness of their repair, are sufficiently characteristic. 
 
 These different types of tertiary ulcerations are connected by 
 numerous intermediate types. There is always a more or less dense 
 and circumscribed specific infiltration of variable depth which 
 has undergone partial necrosis and purulent disintegration. Their 
 clinical evolution is very irregular, sometimes sluggish, sometimes 
 rapid. Their own characteristics commonly suffice for a positive 
 diagnosis, even in the absence of a history or other evidence of 
 syphilis, which, however, should always be looked for. The Wasser- 
 niann test and sometimes examination by biposy may be required. 
 In some cases the mycoses must be kept in mind. These tertiary 
 syphilides are usually very amenable to the influence of specific 
 treatment . 
 
 Tuberculosis.- The various types of ulcerations referable to 
 tuberculosis differ in their appearance, their seat, their pathogenesis 
 and also to a high degree in their virulence, but they are associated 
 by connecting links. 
 
 Tuberculous Ulcer. — Typical tuberculous ulcers possess peculiar 
 features which as a rule permit them to be quite easily recognized. 
 Their seat of predilection is on the lips or tongue, or at any point of 
 the mouth or pharynx; frequently also about the circumference of 
 the anus; rarely elsewhere. 
 
 These ulcers are of ovoid, polycyclic or irregular shape, of an 
 extent varying from a few millimeters to 1 or 2 cm., with wavy or 
 ragged contours, perpendicular or detached borders, of a livid or 
 purplish color, an uneven roughened granular floor, dotted with 
 hemorrhagic points, often partly covered by grayish detritus. 
 Tuberculous ulcers are almost invariably superficial, rather shallow. 
 
 On its floor or at its periphery may be seen the yellow granules of 
 Trelat, punctiform or of pin-head size, in greater or less number; 
 or gray miliary ulcerations. 
 
 The discharge is sanious and rarely profuse. The base is soft or 
 .-lightly infiltrated. The regional glands are often enlarged. Always 
 tender on pressure, tubercular ulcers may become distressingly 
 painful when situated at points exposed to traction or friction. The 
 
SUBACUTE ULCERATIONS 
 
 289 
 
 course is very slow, extending over weeks and months, without 
 showing a tendency to spontaneous cicatrization. 
 
 The pathological anatomy of this ulcer is even more characteristic 
 than its clinical appearance (Fig. 101). 
 
 In cases of rapidly progressive phthisis, tuberculous ulcers of the 
 mouth may occasionally be seen to originate and extend within a 
 few days, constituting acute buccal phthisis. 
 
 
 
 m : 
 
 
 rn^j 
 
 •■;.■'-=...■... & -v. :■ 
 
 
 f 
 
 f m 
 
 Fig. 101. — -Histology of tuberculous ulcer of the tongue. Section from the margin 
 of the ulcer. 6, detached margin of the ulcer; u, floor of the ulcer, showing a light 
 fibrinous layer which covers a tissue infiltrated with pus; /, /, conglomerated or 
 isolated tubercles; they are usually composed of one or several central giant cells 
 a collection of clear epithelioid cells and an external zone of lymphocytes and plasmo- 
 cytes. None of these tubercles is in direct contact with the ulceration ; g, a tubercle 
 developed in a papilla; its enlargement or its confluence with other neighboring 
 tubercles would give rise to a yellow granule of Trelat; m, striated muscle fibers of 
 the tongue. X 40. 
 
 Sometimes, the ulcer assumes the characteristics of the fissured 
 variety being elongated in the diretion of a fold and resembling a 
 rhagade with one irregularly ulcerated portion. This is observed 
 at the commissures of the lips, their median furrow, on the lateral 
 borders or at the tip of the tongue, at points irritated by carious 
 teeth; or again in the radiating folds of the anus, whence the ulcer- 
 ation may extend to the anal canal on the one hand and to the 
 integument of a buttock on the other. 
 
 The papillomatous ulcerative variety, resulting from a combination 
 of the ulcer with a process analogous to that of papillomatous or 
 19 
 
290 ULCERATIONS AXD ULCERATIVE DERMATOSES 
 
 verrucous tuberculosis, is likewise not uncommon. The bare or 
 keratotic papillomatous elevations develop on the congested and 
 cyanotic floor at the border of the ulcer. This variety is seen 
 especially on the lips and at the anus. 
 
 The diagnosis of tuberculous ulcer is usually easy. Traumatic 
 ulcerations heal rapidly when properly treated. Soft chancre is 
 exceptional outside of the genito-anal region, has an abundant sup- 
 puration, a rapid course and is auto-inoculable. Syphilitic ulcers 
 have a more regular form and an indurated base; in difficult or 
 doubtful cases, recourse may be had to serodiagnosis and the demon- 
 stration of the bacillu.-. Asuspicionof ulcerated epithelioma makes 
 the microscopical examination by biopsy imperative. 
 
 Whenever the clinical features of the ulcer — although fairly char- 
 acteristic — and the conditions under which it appears are not suffi- 
 cient to remove all doubts, the diagnosis must always be confirmed 
 by laboratory tots. The tissue-fragments obtained by scraping 
 the floor, or better still from under the margins of the ulcer, contain 
 bacilli; but it is necessary to scrape the tissues rather forcibly with 
 a curette, bringing a little blood. Biopsy also must go rather deep. 
 Inoculation into guinea-pigs may sometimes be necessary. 
 
 Lupus Ulcerations. — The ulceration of a lesion of lupus, whether 
 delayed or appearing at once on a lupus exedens, always presents 
 certain definite features which have been pointed out by Du Castel. 
 
 The borders are slanting, the adjoining tissue is purplish or 
 brownish-yellow, tense, infiltrated, more or less transparent, soft, 
 swollen, or covered with flabby proliferations. 
 
 The shape of the ulcer is round or oval, somewhat regular. Its 
 floor is slightly depressed, of a lardaceous gray, light red or brownish 
 color, sometimes proliferating; it bleeds easily, is of spongy con- 
 sistence and is readily lacerated. 
 
 The base is the seat of a soft, non-plastic infiltration, more often 
 movable than adherent to the subjacent tissues. 
 
 The secretion is turbid, sanious, drying in thin adherent grayish- 
 yellow crusts, which are deeply imbedded and rarely ostreaceous. 
 
 Extension may be either superficial (lupus serpiginosus) , or deep 
 I lupus terebrans), or finally in all directions (lupus vorax). 
 
 Ulcerated Tuberculides. — Leaving out of consideration the minute 
 punctiform ulcerations of the papulo-necrotic tuberculides, mention 
 musl lie made of the sometimes extensive ulcers of erythema indur- 
 (ituin. They constitute rather deep depressions, with variable 
 borders, a grayish or mammillated and reddened floor and an exten- 
 sively indurated base, all of which taken together with the purplish 
 hue of the circumference and the seat of the lesion on the legs, invests 
 them with a peculiar appearance (Fig. 102). 
 
 Occasionally they coincide with scrofulo-tuberculous gummas. 
 
SUBACUTE ULCERATIONS 
 
 291 
 
 Atypical Tuberculous Ulcers. — Under this name I describe a clinical 
 form which is not very uncommon and the diagnosis of which is 
 always most baffling. These ulcers are usually met with in youthful 
 individuals of the female sex who at the same time present either 
 pulmonary lesions with a sluggish course, or cutaneous tuberculides. 
 
 Fig. 102. — Large ulcerated tuberculide of the thigh, in a young woman suffering 
 besides from scrofulo-tuberculous gummas and papulo-necrotic tuberculides. Cure in 
 six weeks, under the influence of rest, good hygiene, injections of tuberculin and aseptic 
 dressings. 
 
 The ulcers are rounded, oval, or polycyclic, from the dimensions 
 of a silver quarter to that of the palm of the hand, single or multiple, 
 situated on any part of the integument. I have observed them on 
 the shoulder, the neck, the chest, the groins, thighs, instep, etc. 
 The irregularly outlined borders are often partly sloping, partly 
 perpendicular or detached, of a dusky red or purplish color; the 
 floor is grayish or bright red and proliferating; there are no yellow 
 points, no lupus nodules; the base is slightly infiltrated and not 
 indurated; they are absolutely painless. The course is extremely 
 sluggish (Fig. 103). 
 
 The diagnosis lies between ulcerative tertiary syphilide, con- 
 genital syphilitic ulcer, abnormal tuberculous ulcer and ulcerated 
 tuberculide. Laboratory investigations are required and yield 
 
292 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 variable results. In the form of atypical tuberculous ulcer 
 described by Man-el LeVy-Bruhl (These de Paris, L914), the his- 
 tological lesions are clearly tubercular associated with vascular 
 changes; the local tuberculin reaction and guinea-pig inoculation 
 are positive. 
 
 In clinically analogous eases I was unable to produce tubercular 
 infection in guinea-pigs. The degree of virulence of these atypical 
 ulcers is accordingly not uniform. They are apparently due to 
 bacillary emboli rather than to external inoculations. The treat- 
 ment of election is surgical extirpation; aside from this, a very 
 favorable action is exerted by tuberculin therapy and radiotherapy, 
 combined with scarifications. 
 
 .luloso 
 
 ilcer < >f the presternal region, co-incident with 
 : i trc-< 1 seventeen years. Case of Levy-Bruhl. 
 
 Leprosy. The ulcers 
 course and pathogenesi: 
 differentiated from tub 
 are observed especially 
 
 if leprosy have a variable appearance, 
 First, the ulcerated lepromas must be 
 
 •les or subcutaneous nodosities. They 
 countries where leprosy is endemic, in 
 
 severe cases, affecting neglected and badly cared-for individuals 
 who drag along a miserable existence. The loss of substance results 
 from partial disintegration of a bacillary infiltration, the remains 
 of which are found at the circumference and at the base and becomes 
 aggravated in consequence of vascular lesions and secondary infec- 
 tions. These lepromatous ulcers lead to serious mutilations. 
 
SUBACUTE ULCERATIONS 293 
 
 Leprous individuals are, on the other hand, exposed to trophic 
 ulcers, especially in the nervous or mixed types. Consecutive to, 
 or associated with pemphigus leprosa, these are very superficial at 
 first but obstinate and soon become covered with a rupioid crust; 
 later on, they spread but retain a regular configuration, perpen- 
 dicular walls and a membranous floor. They are hyperesthetic or 
 anesthetic. When there are no other symptoms besides anesthesia, 
 the ulcers are characteristic of Lazarine leprosy. Bacilli may be 
 found in these ulcers at the period of onset. 
 
 Glanders. — The ulcerations which follow upon the abscesses or 
 nodosities of chronic glanders, formerly called farcy, may present 
 a fairly characteristic appearance, or on the contrary very closely 
 simulate tuberculous, syphilitic or epitheliomatous ulcers 
 
 The features peculiar to them are: their irregular shape, their 
 livid purplish margins, undermined and ragged as if torn by the teeth 
 of mice, their very irregular sinuous floor, the softness of their base, 
 their painlessness; furthermore, the presence of fluctuating nodosities 
 or small abscesses at their periphery. 
 
 Mutilating glanders is apt to be situated in the center of the face, 
 and causes considerable disfigurement and mutilation. The course 
 is slow, irregular and progressive. The usual outcome is death. 
 
 The diagnosis can be surmised under certain conditions, but is 
 positively established only by means of cultures and animal inocu- 
 lation. 
 
 Dermatomycosis. — The ulcerations of sporotrichosis, blasto- 
 mycosis, actinomycosis, and mycetoma (Chapter XXYIII) follow 
 gummous nodosities, or sometimes after tuberculo-ulcerative and 
 ecthymato-pustular dermic lesions. The pus contains the specific 
 parasites, demonstrable on direct examination or by means of 
 cultures. 
 
 Phagedena. — Phagedenic ulcers are characterized by a very 
 marked tendency to invade the neighboring tissues, superficially 
 or deeply, continuously or with interruptions; or rather at intervals; 
 they are accordingly acute in their course and chronic, in their 
 duration. 
 
 These ulcers take their start in various lesions, as if due to the 
 effect of a complication or a malignant change. The initial lesion is 
 very often a soft chancre, rarely a hard chancre and not infrequently 
 a tertiary ulcerative syphilide or a congenital syphilide; sometimes 
 it is a lesion of ecthyma or a patch of spontaneous gangrene. 
 
 It goes without saying that not all extensive ulcerations must be 
 grouped under the heading of phagedena — such as malignant 
 secondary syphilides, tertiary syphilitic ulcers, tuberculous ulcers, 
 cancerous ulcers, the ulcers of tropical diseases, etc., — but only 
 those which assume a both prolonged and rapidly destructive course, 
 
2!)4 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 not an ordinary attribute of their kind. The phagedenic nicer of 
 hot countries will he discussed further on. 
 
 Provided the necessary exclusions are carefully made, it will be 
 seen that no matter what may he the original lesion, phagedenic 
 nicer presents a rather uniform picture, to he presently described. 
 Tin- observation has led the majority of writers to believe that 
 phagedena is due to a superadded infection, a special bacterial 
 agent, or a microbic association of particular virulence. Bacteriology 
 having not as yet confirmed this theory, the conditions of the soil 
 have been held responsible. It is true that phagedena sometimes 
 attacks weakened or alcoholic subjects, but often also robust 
 individuals; one is obliged to suspect in the latter a peculiar sus- 
 ceptibility or a deficient resistance against certain infections agents. 
 Although the majority of cases of phagedena occur in syphi- 
 litica, they do not all have syphilis. Age and sex are apparently 
 irrelevant. 
 
 A phagedenic nicer is of very variable extent, according to the 
 activity and duration of the process. In a few weeks or months, 
 starting from the genital organs, it may have destroyed the larger 
 part of the penis or the vulva, reached the thighs, the perineum and 
 the buttocks; have invaded a considerable portion of the abdomen 
 and the back; in the face it may have destroyed the nose, the lips, 
 a cheek, etc. It involves practically always the entire thickness of 
 the integument; when it burrows deeply, exposing the muscles, 
 tendons, large bloodvessels, etc., it is described as terebrans: it is 
 called serpiginous when it becomes partly cicatrized while elsewhere 
 progressing. 
 
 The configuration of the nicer is sometimes irregular, often poly- 
 cyclic. Brocq pointed out an objective appearance which is most 
 characteristic and which lie names geometrical phagedena, because 
 its distinctly marked borders form perfect circles or ovals or parts of 
 circles and ovals as if traced with a compass. 
 
 The borders, surrounded by a red and infiltrated zone, from 4 
 to 20 mm. wide, are perpendicular, sometimes undermined, with 
 pockets of pns; in other eases sharply sloping. The floor, after it 
 has heen cleansed of the thick and yellow, rather than sanions pus 
 which covers it, appears raw, red and granular, or sprinkled with 
 shreds of sphacelated tissues. The center is sometimes epidermi-zed 
 and crusted. 
 
 The invasion is rapid, fulminating in some eases; as a rule, its 
 progress is much more pronounced at some points than at others. 
 The corresponding glands are usually swollen and painful, but they 
 rarely suppurate. Although sometimes painless, the nicer is more 
 apt to he tender or even extremely painful on contact. 
 
 Histological examination shows a severe phlegmonous process 
 
SUBACUTE ULCERATIONS 295 
 
 with a tendency to rapid necrosis, but a not very extensive range 
 (Dominici, Rubens-Duval and CI. Simon). 
 
 Bacteriology shows nothing but staphylococci, often streptococci, 
 but no specific agent. Fuso-spirillary organisms and the Bacillus 
 ramosus of Villon are absent. The search for anaerobes will have 
 to be kept up. 
 
 Personally, in all cases which I have recently observed, the bacil- 
 lus of Ducrey has been looked for without success; but I have 
 always found the pus to be auto-inoculable on the patient's arm, 
 producing a typical chancroid, only remarkable by a delayed develop- 
 ment which may last from three to five days. [It is noteworthy 
 that in these inoculated chancroids phagedenism does not develop]. 
 This would lead me to assume that a large proportion of the most 
 characteristic phagedenas, although evidently not all of them, are of 
 chancroidal character. Caution is needed, for it is not in the nature 
 of the chancre bacillus to remain indefinitely virulent in the same 
 subject; furthermore, phagedena rarely gives rise to spontaneous 
 auto-inoculations or chancrous bubos. 
 
 Although the appearance of phagedena, as previously stated, is 
 nearly always uniform whatever its origin, it is desirable to point 
 out some peculiarities of the various formerly admitted types. 
 
 Chancroidal phagedena is by far the most common. It originates 
 in a soft chancre or in an open chancrous bubo and is therefore 
 observed especially in the genital and inguinal regions. It does not 
 possess the special features of chancrous ulcer, cracked or fissured 
 borders, a yellowish worm-eaten floor, etc. I have seen it growing 
 by true subdermal abscesses, opening at the surface or under the 
 margins of the ulcer, where they form burrows and extensive puru- 
 lent tracts. Chancrous phagedena, derived from a syphilitic chancre, 
 is rare, unless one comprises incorrectly under this denomination 
 the giant chancres and perforating chancres (terebrans) which may 
 perforate the urethra in men, or the labia of the vulva, the lips, etc. 
 
 Tertiary phagedena, referable to a tuberculo-gummous syphilide 
 or a gumma, has its seat of predilection in the middle of the face or 
 on the genital organs. It may cause enormous mutilations, with 
 fulminating rapidity, destroying, for example, the cheek, the nose, 
 the upper jaw, the turbinates, the roof of the palate, hollowing out 
 an enormous cavity in the middle of the face; the destruction is no 
 less considerable in the pharynx or about the genitals. On the trunk 
 and the extremities, it has been noted that phagedena often exposes, 
 without attacking them, the large bloodvessels and the nerves. 
 
 The course of the phagedenic process varies in different cases, 
 and even in the course of development of the same case. Par- 
 tial cicatrization by itself alone is not a reassuring symptom, for 
 extension may continue elsewhere or the cicatrix become eroded in 
 
296 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 its turn. The total duration of the course of a phagedena usually 
 extends over several years, up to four or five years, ten years or 
 longer. The patients do not become cachectic, but the exquisite 
 pain with each dressing causes them to become weakened and 
 demoralized. Death from hemorrhage or septicemia rarely super- 
 venes. 
 
 Treatment.- In the presence of genuine phagedena, in a syphilitic 
 patient, general specific treatment must not be considered as suffi- 
 cient. Mercurial medication, even when energetic and supported 
 by adjuvants and excellent hygiene, usually fails; intravenous 
 injections of arsenobenzol are positively indicated at the present 
 day, hut may prove insufficient. 
 
 In view of the rapidity with which phagedena exerts its destruc- 
 tive effects, local medication is imperative and must be very ener- 
 getic from the start. The method of choice is the destruction of the 
 infectious focus as a whole with superheated air, under general 
 anesthesia. Extensive removal with the bistoury is likewise advo- 
 cated, in the rare cases where it is practicable. When these measures 
 are inapplicable, recourse must be had to cauterization with the 
 thermocautery, zinc chloride, or tincture of iodin, which are of 
 value only provided all the anfractuosities of the ulcer are reached. 
 At the same time, or in the milder cases, repeated irrigation 
 or washing with peroxide solution or hot potassium perman- 
 ganate solutions. All kinds of antiseptic dressings and all varieties 
 of powders have been tried. Brocq has obtained excellent results 
 with a 10 per cent, collargol salve. [The Carrel-Oakin solution 
 ought to give good results]. In these cases where the presence of 
 chancroidal virus is probable or certain, no time should be lost with 
 iodoform or silver nitrate, etc., but the heroic measures named above 
 should be employed, notably hot air. Auto-inoculation on the arm, 
 which experience has shown to be devoid of special danger, will 
 serve to show if at a given point which may continue to appear 
 suspicious after the general cauterization, virulent germs are still 
 present and require renewed intervention. General tonic treatment 
 and excellent hygiene, although insufficient by themselves, may 
 favor the cicatrization after the ulcer has been transformed into a 
 simple wound. 
 
 ULCERS. 
 
 Ulcus Cruris. I leer of the leg, also known as .simple ulcer or 
 varicose ulcer, is a syndrome into the etiology of which a large 
 number of conditions of various kinds enter. 
 
 The seat of predilection of simple ulcer is on the lower half of the 
 legs, somewhat more frequently on the left leg, at the inner aspect 
 and above the malleolus. It is usually single, sometimes multiple, 
 
ULCERS 
 
 297 
 
 and in this case with a tendency to coalescence of the various ulcers ; 
 its shape is oval, polylobar or polycyclic and its extent may reach 
 15 and 20 cm. in diameter. Its floor is bright red or purplish, pro- 
 liferating, oozing, or, in the absence of suitable care, covered with 
 grayish detritus and sanious offensive pus. The borders are ad- 
 herent, gently sloping or perpendicular, sometimes detached, thick- 
 ened and callous (Fig. 104). The discharge is very variable, scanty 
 and seropurulent when the patient remains in bed. 
 
 Fig. 104. — Varicose ulcer of the leg, with callous margins. 
 
 Sensibility is usually diminished and delayed on the ulcer and in 
 its circumference, especially thermic sensibility, although painful 
 and tactile perception are also lessened. 
 
 The periphery of the ulcer may be erythematous in a more or less 
 extensive area, but otherwise normal; this is rare. As a rule, the 
 neighboring and adjacent tissues are the seat of various changes, 
 some depending on causes which have prepared the soil of the ulcer, 
 others on secondary infections, unclean dressings, etc. 
 
 The complications consist of: Varicosities, which will be referred 
 to again presently; varicose eczema, often circumscribed, which 
 
298 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 may be dry, scaly, cracked, crusted, oozing, rubrum, impetiginous, 
 etc., pigmentation of clay color, resulting from repeated intradermic 
 hemorrhages; lymphangitis, more or less acute, or mild and recur- 
 rent; edema, sometimes soft and plastic, or more frequently non- 
 depressible, elephantiasti< — a hypertrophic callous state, or on the 
 contrary a sclerotic atrophy. These last named lesions are entitled 
 to a moment's attention. 
 
 Leu ulcer in the callous state has thickened, infiltrated, prominent 
 borders, of cartilaginous or woody hardness; they slope rapidly in 
 both directions and particularly steeply on the side of the loss of 
 substance, which is often pale and covered with grayish detritus. 
 The induration extends below the ulcer, and more or less far on the 
 leg and foot; it involves not only the skin, but all the subjacent 
 tissues, down to the bones. 
 
 These callous ulcers are sluggish, obstinate, extensive and not 
 readily curable. 
 
 The fibrous induration may terminate in hypertrophy, in a second- 
 ary elephantiastic state, determined by inflammatory lesions of the 
 lymphatics, bloodvessels and nerves. The bulk of the limb may 
 become enormous and present deformities — which will be discussed 
 under the heading of elephantiasis — with a supramalleolar cushion 
 and swelling of the dorsum of the foot and the toes. The surface 
 is smooth or hyperkeratotic, or more frequently papillomatous and 
 verrucous. 
 
 In other cases the skin in the vicinity of the ulcer is in a state of 
 diffuse or reticulated sclerotic atrophy; under these conditions it is 
 thickened, smooth, tense, cannot be folded and presents a mottled, 
 white, brown or purplish color. It is common for this dermato- 
 sclerosis to precede the formation of the ulcer. 
 
 The inguinal glands are often enlarged, the tendon reflexes of the 
 limb may be absent; there is sometimes a slight muscular atrophy. 
 
 The nails of the foot are usually discolored, opaque, stratified, or 
 even in a condition of pronounced onychogryphosis. It is not rare 
 t'oi- the hairy system to be hypertrophied and for hyperidrosis to 
 exist. These accessory lesions are often present on both sides, 
 although the leg ulcer is unilateral in the majority of the eases. 
 
 Varicosities, which almost invariably accompany ulcer of the leg 
 and exist on both lower limbs, rarely form large subcutaneous 
 strands. The latter do not predispose to ulcer so much as the deep 
 varicosities, which are not very visible and are not perceived unless 
 the patient stands up, or by very careful palpation. They give rise, 
 prior to the formation of the ulcer, to pigmentations in patches, 
 reticulated, or in the form of an areola around a cicatrix; to telan- 
 giectasis; predispose to edema and eczema, and cause cramps, 
 itching and a sensation of heaviness of the limb. 
 
ULCERS 299 
 
 The ulcer begins in a variable manner; as the result of a wound, 
 an ecchymosis, a small traumatic scar, a venous rupture, a small 
 focus of phlebitis, an eczematous lesion, an impetigo or ecthyma 
 pustule — all these lesions, instead of rapidly healing as they would 
 on a well-nourished soil — persisting, becoming infected, deepening 
 and enlarging under the crust which covers them. 
 
 It is exceptional for leg ulcer to begin as a plaque of spontaneous 
 gangrene, although I have several times observed this occurrence. 
 
 Etiology. — Ulcer of the leg is observed especially between the 
 ages of thirty-five and sixty years, slightly oftener in the male sex, 
 in fatiguing occupations which require the erect position; in women 
 who have had numerous pregnancies and in the poorer classes. 
 The patients are, as a rule, atheromatous; sometimes polysclerotic, 
 especially with renal sclerosis. 
 
 To the role played by deep varicosities as an etiological factor, 
 established by Verneuil, has been added that of neuritis, deemed by 
 Quenu to be itself of varicose origin; furthermore, that of arteritis. 
 
 It is readily understood that these general and local conditions 
 impede the healing of the small above-enumerated lesions. This is 
 not all, however. On this undernourished and poorly resistant soil, 
 microbic infections are grafted and come to play the decisive part 
 in the ulcerative process, in the recurrent lymphangitides, and in 
 their sequel, dermatosclerosis. 
 
 Among the innumerable microorganisms of all kinds which 
 flourish on these ulcers, the principal pathogenic agent seems to be 
 most commonly the streptococcus. Leg ulcer has been described as 
 "a chronic streptococcic chancre" (Sabouraud). 
 
 This local streptococcia is indefinitely prolonged, sometimes 
 latent during long periods of time; not infrequently, the presence 
 of the Bacillus pyocyaneus is likewise demonstrable. 
 
 Still other parasites when favored by special local conditions may 
 undoubtedly give rise to a symptom-complex identical with that of 
 simple ulcer. 
 
 It has long been noted that leg ulcers of typical appearance, in 
 admittedly syphilitic individuals as well as in cases of undetected 
 syphilis, will heal under mercurial medication. More recently, 
 objectively similar cases have been recognized as tuberculous, 
 through experimental inoculation. It is not known, however, to 
 what extent these specific infections are involved. 
 
 Diagnosis. — The essential point consists, not in the recognition of 
 the syndrome of leg ulcer, but in determining what part is referable 
 to general and local predisposition as well as to the ordinary or 
 specific infections. 
 
 Simple ecthyma is distinguished by the multiplicity of its lesions, 
 their acute inflammatory character and their course. 
 
300 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 Ulcerative syphUides and syphilitic gummas are usually multiple 
 and bilateral, preferably situated on the external aspect of the legs. 
 The former are often grouped in ares of circles. Gummas begin as 
 a nodosity and, after ulceration has occurred, are characterized by 
 their rounded shape and undermined borders. 
 
 So-called tuberculous ulcer* follow upon bony lesions or scrofulo- 
 tuberculous gummas, or upon fungoid or lupoid tuberculosis, which 
 are recognized by their special features. 
 
 Ulcerative erythema induratum of Hutchinson's type is met with 
 only in youthful persons. 
 
 As stated above, these affections may lose their specific marks in 
 a varicose and sclerotic territory. 
 
 Treatment. — This is medical or surgical. Innumerable methods 
 and remedies have been advocated. In the first place, it is most 
 essentia] to insist upon rest in the recumbent position, with the foot 
 slightly elevated. The inflammation should be soothed and the 
 ulcer cleansed by prolonged local baths, application of powders, 
 aseptic or weakly antiseptic cytoplastic moist dressings. Strong 
 antiseptics being rather injurious. [Liq. aluminii acetatis, one part 
 to ten of water is one of the best of these moist dressings.] 
 
 After improvement has begun and the inflammation subsides, the 
 formation of healthy granulations must be stimulated by means of 
 dry dressings with inert or weakly stimulating powders, aristol, 
 iodoform, iron subearbonate, collargol, etc., the old styrax oint- 
 ment, which has lost nothing of its value as a stimulant, as well as 
 balsam of rem. 
 
 Modern procedures may also be resorted to, such as light baths, 
 radiotherapy, high-frequency currents, hot air; they sometimes 
 exert a highly favorable action. 
 
 Imbricated strips of adhesive plaster, or better still, dressings with 
 cotton or zinc glycerin-gelatin, which is valuable in these cases, or 
 with elastic bands, may permit the patient's attending to some of 
 his work. It is advisable not to change the dressings too frequently 
 in leg ulcers that are healing. 
 
 The remarkably rapid healing of certain leg ulcers of ordinary 
 appearance under the influence of mercurials, notably calomel 
 injections, led to the adoption of the general rule always to give 
 mercury a trial. At the present day, serodiagnosis should be called 
 upon in all such cases and its indications be followed. 
 
 Surgical procedures, such as circumvallation, radiating incisions, 
 etc., are merely mentioned by name in this connection, but it should 
 be kept in mind that carefully and judiciously applied grafts may 
 greatly shorten the time of cicatrization and furnish a better scar. 
 In a few incurable cases of callous ulcer surrounding the entire leg, 
 amputation has proved unavoidable. 
 
ULCERS 301 
 
 After a leg ulcer has healed all efforts are in order to guard against 
 recurrence. Roller bandages, elastic stockings, massage, local and 
 general hygiene, may act efficiently in this connection. Electro- 
 therapy in the form of ionization, combined with radiotherapy, is 
 very serviceable for the control of dermatosclerosis. 
 
 Phagedenic Ulcers of Tropical Countries. — In the hot and moist 
 climates of the tropical and subtropical zone of both hemispheres, 
 ulcers of as yet undetermined character have been observed, which 
 are called tropical ulcer, or according to the regions where they 
 occur, Annamite ulcers, Mozambique ulcer, malgache, etc. 
 
 It is more than probable that this syndrome comprises altogether 
 dissimilar types and has often been made to include ulcerative 
 syphilides, chancrous phagedenas, leishmaniosis, varicose ulcers, 
 etc. Tropical ulcer is usually situated in the lower third of the legs, 
 or on the dorsum of the foot, very rarely on the hands, exceptionally 
 elsewhere. It begins as a papulopustule which becomes gangrenous 
 and spreads. It has rounded or oval contours, flat, unthickened 
 borders and often a concave or funnel-shaped center. 
 
 An atonic form has been described ; the sometimes very extensive 
 loss of substance has a grayish, diphtheroid or sanious floor and a 
 serpiginous outline; repair is delayed a long time and recurrences 
 are common, even after several years. 
 
 The rapid, phagedenic or gangrenous form is extensive or per- 
 forating and advances in acute attacks, sometimes associated with 
 fever; the ulcer is lined with soft fetid masses; it makes deep bur- 
 rows, opens tendon sheaths and joints, exposes the bones, becomes 
 complicated by lymphangitis or neuritis and gives rise to mutilations 
 and fault)' cicatrices. After a certain length of time, it may become 
 atonic. 
 
 In both forms, a sensation of heat and sometimes intolerable pains 
 are present. There is practically no tendency to spontaneous cure, 
 except when the patient moves to a different climate. 
 
 Tropical ulcer is observed in wretched and exhausted individuals, 
 weakened by alcohol, malaria, etc., especially in those who work 
 with bare feet in water, as in rice plantations, etc. 
 
 The starting-point is an excoriation or a wound, the bite of a 
 leech, or mosquito, a pustule of ecthyma, an ulcerative syphilide; 
 briefly, any entrance for infectious microorganisms. 
 
 Tropical ulcer, although only slightly contagious, is inoculable 
 and auto-inoculable; animals are not susceptible. 
 
 A variety of bacilli have been described. Le Dantec and others 
 had observed a matting of bacilli; Vincent (1905) showed it to be 
 caused by a fusospirillary association (Spirocheta schaudinni, Prow- 
 azek 1907), thereby proving its identity with hospital gangrene 
 and ulcerative membranous stomatitis. 
 
302 
 
 ULCER A TIONS A XD ULCER A 77 \ E DER MA TOSES 
 
 Treatment con>ists in first cleansing the ulcer by means of 
 washing and suitable dressings, dry or moist, sometimes assisted 
 bj curettage. After it has been cleansed, washing with a zinc 
 chloride solution, the application of calcium chloride as a powder or 
 of protargol ointment of ."> to 20 per cent. (Castellani) or powdered 
 arsenobenzol is in order, avoiding caustic agents and bland powders. 
 Intravenous injections of arsenobenzol, although sometimes remark- 
 ably effective, may fail unless combined with good local treatment. 
 In all cases, absolute resl is imperative and the general condition 
 musl be improved by appropriate measures. 
 
 Fig. 10."). — Malum perfori 
 itated Mm]. mat ii 
 
 i firsl attack \\1 ich I ad 
 f the first metatarsal. 
 
 From the prophylactic viewpoint, it i> well to remember that in 
 hot eoi nitric-, all wounds including the most trifling abrasions*should 
 
 l»c carefully Matched and dressed. 
 
 Malum Perforans. This name has been given to ulcers of small 
 dimensions and very slow course, apparently connected with a 
 trophic disturbance. They are observed in adults and aged indi- 
 viduals, oftener in the male sex, especially in the course of tabes, 
 sometimes diabetes, syringomyelia, leprosy, polyneuritis, arterio- 
 sclerosis ami sometimes without a demonstrable cause. 
 
ULCERATIONS OF MUCOUS MEMBRANES 303 
 
 Malum perforans plantaris, studied by Nelaton, has its seat of 
 predilection under the head of the first or fifth metatarsal, or at the 
 heel, or on any other point of the foot exposed to pressure (Fig. 105). 
 There are sometimes several ulcers and both feet may be affected. 
 
 The disease usually begins as a painful corn, a rounded hyper- 
 keratosis on which blisters are repeatedly formed, or as a small 
 crust. Before long, under the horny covering or under the crust, 
 a rounded ulcer is found, with a proliferating or atonic floor, with 
 perpendicular walls surrounded by hyperkeratosis. It burrows 
 more or less deeply, and may reach the tendons, joints and bones and 
 the latter when examined by .r-rays are often found to be altered. 
 
 This lesion is painful on strong pressure, but often entirely 
 anesthetic to needle-pricks in a variable radius. 
 
 Cases of mal. perforans affecting the fingers (malum perforans 
 digitalis), the back of the foot, the nose or mouth, which may be 
 encountered in the course of tabes, as well as mal. perforans of 
 amputation-stumps, are very rare. They consist in losses of sub- 
 stance resembling traumatic abrasions, but occurring spontaneously, 
 painless and anesthetic, often symmetrical, without any inflam- 
 matory reaction and indefinitely persistent. Buccal mal. perforans 
 is often preceded or accompanied by a fall of teeth and frequently 
 gives rise to losses of bony substance through absorption or seques- 
 tration. 
 
 The treatment of mal. perforans plantaris requires rest; the horny 
 masses should be scraped off after moist dressings or a salicylic 
 acid plaster has been applied, followed by curettage or cauterization 
 of the ulcer. The wound is dressed with substances favoring 
 cicatrization. 
 
 High frequency currents have seemed to me to be very efficient. 
 In tabetic cases, healing is not infrequently obtained by intravenous 
 injections of arsenobenzol. In order to guard against recurrences, 
 which are always to be feared, it is advisable to protect the region 
 against all pressure by means of appropriate dressings or special 
 foot-gear. 
 
 In the grave cases associated with suppuration and opening of 
 joints or bony necrosis, partial amputations are sometimes unavoid- 
 able. 
 
 ULCERATIONS OF MUCOUS MEMBRANES. 
 
 Although a comparison of the ulcerations of the various mucosa 
 would be extremely interesting from the diagnostic point of view, 
 the subject is too large for full presentation. I shall therefore discuss 
 only the buccal mucosa (excluding the isthmus of the pharynx and 
 consequently the anginas) and the genital mucosa?. On the other 
 hand, the term "ulceration" will be used in its widest and most 
 
304 ULCERATIONS AX J) ULCERATIVE DERMATOSES 
 
 comprehensive sense, so as to cover the most superficial epithelial 
 abrasions up to the deepest ulcers. It must be conceded, however, 
 that completeness is almost impossible in a subject of this kind. 
 
 Buccal Mucosa. — In considering an ulceration of the mouth, all 
 its features must be carefully noted by the physician, but with 
 special attention to the following points: depth, condition of the 
 surface, configuration, base, number, site, course. Needless to say, 
 the diagnosis will usually be greatly helped by the general exami- 
 nation of the patient. 
 
 1 . Dry Erosions or Depapillated Plaques of the Tongue. — When 
 these are persistent and not dependent upon a stomatitis, an acute 
 infectious disease or a gastric disorder, they should suggest syphilitic 
 smooth plaques, sclerotic glossitis, mild leukoplakia or glossitis 
 inarginata. There are still other smooth plaques the origin of 
 which is not always demonstrable. 
 
 2. Moist and Diphtheroid Erosions. — All vesicles or bullae of 
 mucous membranes are very rapidly transformed through macera- 
 tion and loss of the raised epidermic layer into erosions which are 
 frequently covered with a pseudomembrane. 
 
 Buccal herpes is characterized by round microcyclic erosions, 
 often grouped or confluent, rather painful, not very persistent. 
 This herpes is recurrent in certain individuals. 
 
 Buccal zona, which is extremely rare, is said to be unilateral and 
 non-recurrent. 
 
 Artificial bullae, resulting from burns, produced by a cigar, for 
 example, are often of irregular shape and obvious localization. 
 
 Hydroa and Duhring's disease are accompanied, in about one- 
 half of the cases, by buccal lesions on the inner surface of the 
 checks, the posterior surface of the lips, the palate, sometimes on 
 the tongue or on the isthmus of the throat; in the form of rounded 
 or superficially confluent bright red erosions partly covered by a 
 membranous or diphtheroid layer and extremely painful. The 
 coexistence of the cutaneous eruption reveals their true character. 
 
 Chronic pemphigus has, on the contrary, a nearly constant and 
 often primary buccal localization; it may remain the sole mani- 
 festation for many weeks. 
 
 In the few cases which have come under my observation, the 
 pillars of the fauces, the pharynx, the cheeks and, later on, the lips 
 and the borders of the tongue presented grayish or sanious, friable 
 or adherent false membranes, covering partially ulcerative and 
 oozing erosions, of irregular form and slowly progressive course. 
 Objectively, the condition suggested diphtheria, Vincent's stoma- 
 titis, a medicinal stomatitis, or even syphilides. The pains were 
 intolerable, the odor was offensive, the glands were enlarged; the 
 general condition was seriously affected, with slight fever, but very 
 
ULCERATIONS OF MUCOUS MEMBRANES 305 
 
 rapid emaciation. The diagnosis, rendered probable by these con- 
 ditions and by the presence of a slight bullous elevation at the 
 margin of the erosions, was confirmed by the appearance of blebs 
 in the genital region and on the fingers. The gravity of this fearful 
 disease is well known. 
 
 Syphilitic mucous patches are the most frequent buccal erosions 
 and ulcerations and those which it is most important to know. The 
 general description and that of the principal varieties are given else- 
 where in this book (p. 620). It must be kept in mind that it is not 
 justifiable to base the diagnosis of syphilis simply on the demon- 
 stration of lesions presenting the appearance of mucous patches, 
 for they are not characteristic in themselves (A. Fournier); the 
 coincidence of other manifestations with their special chronology 
 is required or the demonstration of the Spirocheta pallida, a posi- 
 tive Wassermann reaction, generalized glandular enlargements, 
 etc. 
 
 Syphilitic chancre is ordinarily erosive on the tongue. It is seen 
 at the extreme tip of the organ, in the form of a fissured erosion; or on 
 the dorsal aspect of the anterior third, in the form of a lenticular 
 or oval, pink or sometimes grayish, single and painless eroded spot. 
 Very careful palpation reveals a parchment-like induration at its 
 base; the corresponding glands always assume a disproportionate 
 enlargement as compared to the apparent importance of the lesion ; 
 they are non-inflammatory and painless; occasionally, the glands 
 are the first to attract attention and point to the initial lesion. On 
 the gums the chancre is likewise merely an erosion, frequently 
 semicircular. 
 
 Buccal diphtheria is rarely primary, being generally secondary 
 to diphtheritic angina. It consists of irregular pseudomembranous 
 adherent patches, located on the lips and on the inner surface of 
 the cheeks. The Loefner bacillus is found, either in pure culture or 
 in varied associations. 
 
 Diphtheroid stomatitis is of frequent occurrence in children; 
 the false membrane here is less coherent; it is apparently often 
 due to pyococci. The most distinctive form is impetigo buccalis 
 (impetiginous stomatitis of Sevestre and Gaston), the features of 
 which have been described elsewhere. 
 
 Thrush (soor, muguet) is not an ulcerative lesion, but might be 
 confused with a diphtheroid erosion. It presents the appearance 
 of a pure white or creamy adherent layer on an erythematous base ; 
 when it is detached, the mucosa is seen to bleed. Thrush is observed 
 in cachectic individuals and in little children suffering from digestive 
 disturbances. It occurs on the tongue, the cheeks, the isthmus, in 
 the form of very small elevations which subsequently become con- 
 fluent in ragged irregular patches. On inspection under the micro- 
 20 
 
306 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 scope, the coating is shown to be made up of epithelial debris and 
 very abundant filaments of endomyces albicans. 
 
 3. Ulcerations. In whooping-cough (pertussis) of children, an 
 ulceration of the frenuni of the tongue is observed, caused by its 
 rubbing against the teeth and assisting the diagnosis by its location. 
 Other simple ulcers, especially of traumatic origin, due to bites 
 (as in epileptics) or to friction of the mucosa, are encountered at 
 any age on the border of the tongue, or sometimes on the inner 
 surface of the cheeks or the lips, notably at points which are in 
 contact with some roughening of the teeth, due to dental caries, etc. 
 These ulcerations are deep, of irregular shape with an edematous or 
 sometimes indurated base, painful and usually without glandular 
 involvement. They heal spontaneously after the removal of the 
 offending tooth or roughness and disinfection of peridental foci of 
 suppuration. 
 
 Common a phi ha- are small, punctiform, or at most lenticular 
 yellowish ulcerations, perfectly round or oval, following upon a 
 grayish vesicle and surrounded by a characteristic carmine-red 
 narrow border; they give rise to a very painful burning sensation. 
 They are seen at all ages, always in very small numbers, but these 
 aphthae may come and go for a long time in dyspeptic and nervous 
 individuals following errors in diet, overexertion, or irritative local 
 causes in the mouth. The co-existence of herpes is not uncommon. 
 Inflammatory complications are rare. 
 
 Common aphthae are certainly in no way related to aphthous 
 fever, a contagious disease of bovine origin, apparently trans- 
 missible to man through cows' milk [foot and mouth disease]. 
 According to certain writers, this gives rise to an abundant erup- 
 tion of aphthae in the mouth, together with serious general manifes- 
 festations; but this is not an established fact. 
 
 The ulcero-membranous stomatitis of Rilliet and Barthez and 
 of Bergeron, which is now considered as identical with Vincent's 
 angina and stomatitis, is due to mixed infection with the fusiform 
 bacillus and spirilla; it is easy to demonstrate these parasites, 
 which are seen in large numbers and often in pure cultures on 
 smears of the exudate stained with dilute Ziehl's solution or car- 
 bolized thionin. 
 
 \ incent's stomatitis is observed particularly in children and 
 youthful individuals, especially in weakened or exhausted persons, 
 sometimes in almost epidemical form in crowded places, asylums, 
 barracks, etc. |lt was quite common among the soldiers in the 
 ( rreal War and was known as trench mouth. | The onset is followed 
 Immediately, or after a few days of fever, malaise, and local distress, 
 by salivation, an offensive breath and pain. 
 
 Inspection of the mouth shows swollen and ulcerated gums; on the 
 
ULCERATIONS OF MUCOUS MEMBRANES 307 
 
 cheeks, especially in the vicinity of the last lower molar tooth, 
 then on the entire inner surface of the cheeks and sometimes of 
 the lower lip, rounded ulcerations, or a sinuous ulcerated band, 
 make their appearance. The lesions often invade the sides of 
 the tongue, sometimes the palate and the velum or the tonsils; 
 in some cases they remain unilateral or predominate on one side. 
 
 The following are some of their most essential features: the 
 floor of the ulcers is grayish or the color of wine-dregs, usually 
 masked by pultaceous, sanious, or even gangrenous detritus; per- 
 pendicular borders; a non-indurated base; the teeth are often 
 bared through erosion of the alveolar margin ; severe pain is present ; 
 mastication is impossible ; there is profuse salivation and a peculiar 
 disgusting odor. 
 
 The submaxillary glands are enlarged and painful; the expression 
 of the face is drawn and pale; there is well-marked anorexia; a 
 slight fever may be present. 
 
 When left untreated, the affection may last during several weeks 
 or even months; by proper care, it can be cured in eight to fifteen 
 days. The prognosis is on the whole favorable. 
 
 Syphilitic chancre of the mouth, in contradistinction to tonsillar 
 chancre, is very rarely ulcerative. 
 
 Ulcerative secondary syphilides are observed in the ordinary 
 forms of the disease as well as in precocious malignant syphilis and 
 are characterized by their sharp outline circular form and by the 
 depth of the lesion; they develop rapidly. 
 
 The ulcerative gummas of the tongue and the sclero-gummous 
 idcerations have been discussed elsewhere. 
 
 The ulcerations of leukoplakia deserve special mention. In the 
 patches on 1he tongue, as well as on the cheeks and the lips, there 
 are frequently encountered, not only more or less persistent fissures, 
 but also very peculiar chronic ulcerations which do not seem to 
 have attracted the attention of authors. I have repeatedly called 
 attention to the characteristics of these leukoplasic ulcers. 
 
 Their shape is irregular, often angular; their floor, of a bright red 
 color, smooth or finely mammillated, is frequently raised on a 
 plane up to the level of the borders, from which it is separated by 
 a deep furrow cut out as if with a knife and brought into view by 
 unfolding it. 
 
 Besides being a source of annoyance, obstinate to treatment and 
 frequently recurrent, these ulcers are furthermore alarming because 
 they give rise to the dread of epithelioma; it is reassuring that their 
 base is not more indurated than that of the neighboring sclerotic 
 surfaces. In my opinion they are due to a local nutritional dis- 
 turbance of the mucosa, referable to the underlying sclerosis and 
 arteritis. 
 
308 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 In order to cure them, recourse must be had to calomel injections, 
 intravenous injections of arsenobenzol, or to local mercurial injec- 
 tions of weak concentration. Putting the teeth in good condition 
 and proper buccal hygiene are indispensable. I regard it as inad- 
 visable to irritate these lesions by caustic agents, but have often 
 had good results from the employment of radium or .r-rays. 
 
 Trophic ulcer, malum perforans of the mouth, has been observed, 
 especially in tabetic patients, on the alveolar margin and the bony 
 
 Tuberculous ulcer has already been described. I repeat that the 
 tongue and the lips are among its seats of election. 
 
 I shall not dwell upon the buccal ulcerations of very variegated 
 appearance which occasionally occur in the stomatitides of uremia 
 and diabetes, in scurvy and other severe infectious diseases or con- 
 ditions leading to cachexia. 
 
 Mercurial stomatitis is probably merely a special instance of 
 Vincent's spirillary stomatitis. In its milder forms, it is limited 
 to superficial irregular ulcerations, covered with a white mass, 
 situated at the neck of the last molar tooth and its immediate 
 neighborhood, at the neck of the lower incisors and sometimes on 
 the borders of the tongue. They are accompanied by profuse 
 salivation, a diffuse doughy exudate and a characteristic fetid odor. 
 In the severe forms, however, deep gangrenous ulcerations have 
 been noted, involving the checks, the gums, or even the bones and 
 sometimes true gangrene of the tongue. 
 
 Noma, or buccal gangrene, was described in former times as 
 rather frequent in children between two and four years of age, 
 especially as a sequel of measles or typhoid fever, sometimes occur- 
 ring in epidemic form. 
 
 Noma in children was said to begin as a livid swelling of the 
 cheek; the mucous surface presents one or several blisters, covering 
 livid then grayish sloughs; their fall leaves an ulceration which 
 rapidly spreads and burrows, with ragged margins and a sanious, 
 irregular, horribly offensive floor, sometimes perforating the cheek. 
 The teeth fall out and the bones become necrotic. Death supervenes 
 in four-fifths of the cases, in eight to fifteen days. 
 
 The condition in all probability represented an ulcero-membran- 
 ous stomatitis, due like hospital gangrene to a fuso-spirillary infec- 
 tion. The very grave eases to which the above description is 
 applicable have fortunately become extremely rare. 
 
 In the tropics, among half-famished and improvident natives, 
 cases of extensive gangrene of the lips and cheeks are observed, 
 suggestive of noma and perhaps referable to the same etiology, 
 but more probably the result of phagedena of various kinds. 
 
ULCERATIONS OF MUCOUS MEMBRANES 309 
 
 4. Ulcerative Neoplasms. — In the cases of tuberculo-ulcerative 
 syphilide of the buccal cavity, or in the less common cases of ulcer- 
 ated lupus of the buccal mucosa, it is readily seen that the ulcera- 
 tions are not primary, but develop on a neoplastic patch having the 
 features described above. They are generally multiple, rounded, 
 perpendicular, with a relatively hard base in case of syphilis; 
 irregular, less deep, with soft borders, in case of lupus. 
 
 Epithelioma of the buccal cavity is, in the great majority of the 
 cases, of the lobulated types. I have, however, seen numerous 
 instances of tubular [basal-celled] epithelioma. 
 
 In the great majority of cases, epithelioma is situated on the 
 tongue or on the lips, sometimes on the cheeks, the pharynx, the 
 palate, the gums, the floor of the mouth. It begins under the 
 papillary form, or as a fissure, as I have pointed out in connection 
 with leukoplakia, and also as a discoid elevation from the start. 
 It becomes eroded very soon and then excavated by an ulceration. 
 
 The characteristics of epitheliomatous ulcer are as follows: 
 Almost invariably irregular shape; very uneven, proliferating, 
 sanious, readily bleeding floor, sometimes interspersed with small 
 yellowish or gray masses; raised, swollen or overhanging borders in 
 lobulated epithelioma, perpendicular borders in the tubular form; 
 the base is always indurated, forming the tumor. Glandular 
 enlargement occurs early in lobular epithelioma and determines 
 an unfavorable prognosis; it is absent or very much delayed in the 
 tubular variety. 
 
 Actinomycotic ulcer of the mucosa has the same characteristics 
 as in the skin. Yellow granules can be extracted from it. The 
 reader is referred to Chapters XXVIII and XXIX for the buccal 
 ulcerations of the sporotrichoses, leishmaniosis, etc. 
 
 Other tumors, notably the sarcoma known as epulis, or even 
 benign neoplasms, may become accidentally ulcerated. 
 
 Treatment of Buccal Ulcerations. — In a general way, much can be 
 accomplished by scrupulous hygiene for the prevention of ulcera- 
 tions of the buccal mucosa. Prophylactic treatment consists in 
 proper care of the teeth and gums; the mechanical removal of 
 tartar, cleansing and filling of carious cavities, extraction of stumps, 
 cauterization of fungoid or soft gums and adjustment of prosthetic 
 apparatus, should be left to the dentist. The results achieved 
 must be maintained by regular brushing with a soapy powder or 
 paste or any good dentifrice. 
 
 These measures are positively required in syphilitics, from the 
 beginning of mercurial treatment, in patients recovering from severe 
 infections, in persons predisposed to herpes, aphtha?, etc. In 
 addition there should be abstinence from tobacco, alcoholic bev- 
 erages and irritating food. 
 
310 ulcerations and Ulcerative dermatoses 
 
 As to curative treatment, only brief suggestions can here be 
 offered. Erosions, opaline mucous patches and aphthae are bene- 
 fited by superficial silver nitrate cauterizations every second or 
 third day; irrigations with dilute peroxide water or potassium 
 chlorate. Soothing mouth washes are sufficient in cases of acute 
 irritation. Mechanical cleansing with a wisp of cotton wet with 
 alkaline or horated solution will suffice in thrush. 
 
 The ulcerations of ulcero-membranous stomatitis are treated with 
 mouth-baths of dilute Labarraque's solution, 1 to 20; cleansing with 
 a small stick wrapped in cotton, followed by touching with silver 
 nitrate; with powdered arsenobenzol, calcium chloride in substance, 
 powdered methylene-blue or iodine tincture. Internally, sodium 
 chlorate, grams 2 per diem, is recommended. Intravenous injec- 
 tions of arsenobenzol are efficient only when combined with 
 proper local treatment. [It is the method of choice in Vincent's 
 infection.] It is highly advantageous to apply to syphilitic ulcers, 
 together with the indispensable general treatment, the various 
 topical agents enumerated above. The treatments suitable for 
 the other cases have been discussed elsewhere. 
 
 Genital Mucosae. — The majority of the erosive or ulcerative 
 affections occurring in the mouth may also be encountered on the 
 genital mucosa? or semimucosse of both sexes. 
 
 This is especially true of herpes, which is common in this location; 
 of syphilitic manifestations of all kinds and of hydroa; on the other 
 hand, aphthae, impetigo, thrush and diphtheria are rare. Again, 
 localizations of various dermatoses are here met with, which do 
 not occur in the mouth, such as eczema, psoriasis, eczematides, 
 scabies and, furthermore, a few special erosions and ulcerations. 
 
 Traumatic excoriations due to coitus, scratching with the finger- 
 nails, rape, etc., often have a characteristic irregular or fissured 
 form; unless complicated by a superadded affection they heal with 
 remarkable rapidity. 
 
 Soft chancre has been sufficiently emphasized and does not require 
 further discussion. 
 
 Gonorrhea gives rise, in men, to a more or less acute diffuse 
 balanoposthitis, sometimes with phimosis and ordinary or follicular 
 erosions at the base of the glans and in the sulcus. Gangrene 
 of the prepuce in these cases is very rare. 
 
 In women, gonococcal vulvitis may be accompanied by small 
 para-urethral follicular ulcerations, by canaliculitis , namely inflam- 
 mation, sometimes ulcerative, of the excretory duct of Bartholin's 
 gland, sufficiently characterized by its seat; finally, by gonococcal 
 erosions of a dusky red, granular surface, distinct or jagged margins, 
 localized especially outside of the caruncuhe myrtiformes. Being 
 frequent and very persistent, these lesions may at the first glance 
 
ULCERATIONS OF MUCOUS MEMBRANES 311 
 
 betray the existence of gonorrhea, which the patient is endeavoring 
 to conceal. 
 
 Diabetes gives rise not only to erythematous, eczematous, etc., 
 balanoposthitis and vulvitis, but also to fissures and ulcerations 
 of very variable aspect, syphiloid in appearance, and even to 
 gangrenes. 
 
 Circinate erosive balanoposthitis manifests itself in the form of 
 extensive polycyclic, superficially erosive lesions bordered by a 
 narrow white margin. This affection, attributed to spirilla by 
 Berdal and Bataille, was recognized by Queyrat as a localization 
 of the fuso-spirillary symbiosis which also causes Vincent's stoma- 
 titis. An analogous affection may be met with in women. In 
 neglected cases, circinate balanitis lasts several weeks and is often 
 recurrent. It is very easily cured by cleanliness and painting with 
 a 1 to 30 solution of silver nitrate. 
 
 Syphilitic chancre, the different varieties of secondary syphilides 
 or mucous patches, and the tertiary syphilides of the genitals have 
 served for the descriptions of the manifestations which I have already 
 given. 
 
 Tuberculosis may manifest itself in the same regions, although 
 this is very rare, as tuberculous ulcer, resulting from a contagion 
 or auto-inoculation and as ulcerated lupus, which is still more 
 rare. 
 
 Under the name of esthiomene, introduced by Huguier in 1848, a 
 rare syndrome is still occasionally described, which is character- 
 ized by a chronic ulceration of the vulva associated with elephan- 
 tiasis. The more or less deep and often painless ulcer is situated 
 at any point of the vulva, preferably at the entrance of the vagina. 
 The sometimes enormous hypertrophy involves the labia minora, 
 the clitoris, the labia majora, the perineal region, etc. 
 
 It is more than likely that the nature of the ulcer is very different 
 in different cases, so that there may be tuberculous or lupus ulcers 
 (Bernutz, Ficquet), soft chancres of low virulence (Jacobi), ulcera- 
 tive tertiary syphilides, analogous with anorectal syphiloma, or even 
 epitheliomas, which as a result of local conditions, notably a lack 
 of cleanliness, become infected and give rise to sclerogenic inflam- 
 matory edema. [An ulcerated infected lymphangioma of the vulva 
 may produce a similar picture.] It has recently been pointed out 
 that the clinical picture of esthiomene is perfectly reproduced in 
 the ulcerative granuloma of the genital organs. 
 
 Ordinary secondarily infected wounds or excoriations may finally 
 suffice for the production of this pathological type, as a sequel of 
 lymphangitis, sclerosis, or removal of the inguinal glands, etc. 
 Esthiomene would in this way become entirely comparable to 
 ulcer of the leg with elephantiasis nostras. 
 
312 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 Treatment of Genital Ulcerations. — No matter what may be the 
 cause and character of a balanoposthitis, phimosis or vulvitis, it 
 is of great importance to keep the parts as clean as possible. If 
 the glans cannot be uncovered for the irrigations, on account of the 
 existing pain and inflammation, injections must be introduced into 
 the subpreputial sack by means of a flexible rubber nozzle, begin- 
 ning with lukewarm cleansing injections with large amounts of 
 water, followed by astringent injections with a 1 : 100 silver nitrate 
 solution, for example, or dilute peroxide water. 
 
 Exposed erosions or ulcerations are treated by touching them with 
 silver nitrate, tincture of iodine, etc., with bland non-fermentable 
 mineral or medicated powders or finally with salves or creams. 
 
 Keeping in mind, however, that cauterizations and numerous 
 topical agents produce an induration which may become misleading, 
 these should not be employed unless the diagnosis is already quite 
 positive. 
 
 In women, it is necessary to emphasize the manner in which the 
 irrigations are to be used so as to be really efficient. It is often 
 advantageous to prevent mutual contact between the parts, by 
 inserting gauze or cotton tampons freely dusted with powders or 
 covered with a layer of zinc ointment. 
 
 In case of important or serious genital ulcerations, notably those 
 of gangrenous appearance, the surfaces must be cleansed by local 
 baths, moist dressings, washing with peroxide water or camphor- 
 ated alcohol; next, iodoform powder may be applied, with a little 
 salicylic acid or camphor, or according to the case, calcium chloride, 
 balsam of Peru, etc. 
 
 Needless to say, all necessary directions must be given for the 
 avoidance of contagion. 
 
 CUTANEOUS GANGRENE. 
 
 Cutaneous gangrene means mortification or death of a portion of 
 the integument and may be accompanied by the same changes in 
 the underlying tissues. When it is abrupt and complete from the 
 onset, it is named necrosis; when it results from a progressive loss 
 of tissue vitality, it is called necrobiosis; this distinction is of small 
 importance, the two processes being frequently combined. The 
 "dead" portion is known as a slough or .sphacelus. It is distin- 
 guished as dry gangrene and moist gangrene, according to its being 
 dry and mummified, or on the contrary, moist, putrefying and fetid. 
 
 Gangrene manifests itself as a change in color of the skin, which 
 at the same time becomes cold and anesthetic to touch, pricking, 
 and temperature. In the case of dry gangrene, the skin is yellow 
 or purple, then brownish, and promptly hardens through desicca- 
 
CUTANEOUS GANGRENE 313 
 
 tion, becoming depressed below the normal level. Moist gan- 
 grene often begins as a purulent bulla, or rather as a bulla with 
 sanious or hemorrhagic contents, the floor of which becomes necrotic ; 
 or a flabby, mottled, grayish surface may on the next day become 
 covered with sanious blebs. 
 
 While sometimes unnoticed by the patient, the process in other 
 cases is preceded or accompanied by stiffness, tingling, heat and 
 intolerable laminating or tearing pains. 
 
 After a few days, unless the necrosis proceeds very rapidly, the 
 slough becomes surrounded by a congestive halo, sometimes bul- 
 lous at its periphery; on the line of demarcation between the dead 
 and the living tissue, a deep groove is formed which suppurates more 
 or less freely. Having become dark brown or black, the sphacelus 
 retracts and is finally cast off, exposing an ulceration covered with 
 detritus, or sometimes pink and proliferating. 
 
 The pathogenic mechanisms to which the various forms of cutane- 
 ous gangrene are due, are multiple. In each particular case, there 
 is reason to look for one or several of the following conditions, which, 
 moreover, instead of excluding one another are very frequently 
 associated : 
 
 A. Direct local action of a mechanical, physical or chemical 
 necrotizing agent. 
 
 B. Suppression of the blood supply (through embolism, arteritis, 
 etc.). 
 
 C. Serious alteration of the blood itself. 
 
 D. Necrotizing infection. 
 
 E. Serious change of the trophic nerve supply. 
 
 The last-named factor, often emphasized in the past (Zambaeo, 
 1859), is at present considered as altogether accessory. Neuro- 
 trophism may sometimes perhaps act as a favoring factor, but the 
 existence of trophic gangrene or necrosis of trophic origin cannot 
 be admitted. So-called hysterical gangrene is always artificially 
 induced. 
 
 The pathogenic mechanism from which certain secondary gan- 
 grenes are derived, for example those which sometimes complicate 
 erysipelas, anthrax, soft chancre, etc., or which originate in malig- 
 nant tumors, cancers, sarcomas, the tumors of mycosis fungoides, etc., 
 is probably complex and cannot always be definitely established. 
 
 A. Direct Local Gangrene. — This results from an injury directly 
 affecting the mortified point. Traumatic gangrene, as a sequel of 
 crushing, severe contusions, war-wounds, belongs to the domain of 
 surgery. Prolonged compression, for example by a very tight plaster 
 apparatus, may produce a direct slough or ulceration. 
 
 Decubitus may have the same effect on the compressed points, 
 especially the sacral region and the trochanteric regions, much more 
 
314 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 rarely the heels or the scapular regions, in patients whose nutrition 
 is seriously impaired and whose vascular tension is lowered by a 
 severe general disease or a disease of the nervous system (dementia, 
 myelitis, hemiplegia, etc.). 
 
 The sloughs of decubitus [bed-sores], which were formerly con- 
 sidered as of trophic origin, are really due to the chronic irritation 
 of the integument by contact with the urine, fecal matter, and cuta- 
 neous secretions, in very weakened or hypersensitive individuals, 
 with secondary infection of the macerated and excoriated skin. 
 They can generally he avoided by extreme cleanliness, aseptic 
 powders, and the employment of air-cushions. 
 
 Physical causes, such as burns, frost-bite, contact with continuous 
 current electrodes, high frequency -park-, ar-rays in excessive doses, 
 will produce gangrenous patches at the damaged point-. 
 
 Fig. 106. — Carbolic gangrene of the thumb, in a child aged five years, who had worn 
 a carbolic acid dressing during one night, for a scratch made by a cat. 
 
 Numerous chemical agents, so-called "caustics," notably strong 
 alkali- and acids, certain -alt-, corrosive sublimate, zinc chloride, 
 etc., will do the same. Sometimes, iodine tincture and even mus- 
 tard plasters may produce sloughs, especially in children. 
 
 Carbolic gangrene \> entitled to special mention, on account of its 
 relative frequency and its insidious behavior. It is noteworthy that 
 the total loss of a finger ha- repeatedly followed upon a simple 
 panaris or whitlow, dressed with a solution of carbolic acid, even in 
 supposedly harmless dilutions (Fig. L06). The patient is not warned 
 by any painful sensation of the impending gangrene. It is therefore 
 advisable to discard carbolic acid dressings, especially for the 
 extremities. 
 
 In the direct gangrenes, the injurious factor usually acts at the 
 same time on the tis>ue constituents themselves and by producing 
 
C U TA NEO US GA NO RENE 
 
 315 
 
 stasis or thrombosis in the capillary bloodvessels. Infection, when 
 present, is superadded. 
 
 B. Gangrene of Vascular Origin. — Any portion of the organism 
 in which the circulation of the blood is completely and permanently 
 arrested, inevitably undergoes necrobiosis or necrosis. The venous 
 system, which is rich in anastomoses, is rarely affected; gangrenes 
 in the course of phlebitis, or of phlegmasia alba dolens, being of 
 exceptional occurrence. Almost invariably, the obliteration is 
 arterial, affects the extremities, and the gangrene is of the dry type. 
 Vascular rupture, sometimes ligature, compression, embolism, 
 especially thrombosis through acute or chronic arteritis, produce 
 different forms of progressive gangrene of the extremities. 
 
 Fig. 107. — Dry symmetrical gangrene of the toes. 
 
 These gangrenes are observed especially on the feet, beginning 
 with one or several toes, attacking at once the skin and the deep 
 tissues, including the bones; hence they do not belong to the domain 
 of dermatology. Only the principal types are here mentioned: 
 Senile gangrene; gangrene due to obliterative endarteritis of 
 Friedlander (Fig. 107) ; gangrene due to syphilitic arteritis [to endo- 
 phlebitis migrans, Buerger]; gangrene in typhoid fever, etc. 
 
 Gangrene of the extremities, as a rule, partial or limited to the 
 fingers or toes, which occurs in the grave forms of Raynaud's dis- 
 ease, is preceded by attacks of " local asphyxia" and " local syncope" ; 
 it has been attributed to a vascular spasm, a mechanism which would 
 
316 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 probably be incapable of producing this result. Its pathogenesis 
 is not known. The rare cases of gangrene observed in progressive 
 scleroderma may be compared with it. 
 
 C. Gangrenes Through Changes of the Blood. —Under this head- 
 ing I group the toxic gangrenes and those gangrenes which may be 
 considered as autotoxic. 
 
 Ergot of rye gave rise in the middle ages to epidemics in which 
 the general phenomena of ergotism were associated with tingling 
 sensations or severe pains and mutilating gangrenes of the extremi- 
 ties. 
 
 Carbon monoxide poisoning is capable of producing gangrene in 
 large patches, or involving an entire extremity. Chloral, when 
 administered for a long time and in large doses, has been accused of 
 the same effects. The question of gangrenes in the course of Bright's 
 disease, which are rather exceptional, is not well understood. 
 
 Diabetic gangrene, on the contrary, is not uncommon. It is 
 observed in individuals who are by no means cachectic, even in the 
 enjoyment of excellent health and without large amounts of sugar in 
 the urine. Assuredly neither hyperglycemia nor neuritis nor even 
 arteritis can be held responsible, except perhaps in the massive 
 forms. A slight traumatism or an accidental cutaneous affection 
 often serves as determining cause. The principal part is probably 
 referable to a local infection, streptococcic or other, or to septic 
 embolisms. 
 
 Massive diabetic gangrene may abruptly attack an extremity, 
 an entire limb, the genital organs, etc. In other cases, gangrenous 
 patches are scattered over the feet, the lower limbs, or elsewhere, in 
 the form of grayish or brown sloughs, preceded by a blister and pro- 
 gressively extensive. In this form — named bullo-serpiginous, by 
 Kaposi — the center may heal while a bullous elevation at the periph- 
 ery marks the zone of invasion. The course is rapid or on the 
 contrary very sluggish. The prognosis in a general way is not very 
 unfavorable. 
 
 When gangrene in diabetics is secondary to suppurative lesions, 
 furuncles, carbuncles, abscess, etc., the symptoms of reaction may 
 be mild, although the situation is really threatening. 
 
 D. Gangrenous Infections. — Infection through bacteria of various 
 kinds, ordinary or special, aerobes or perhaps especially anaerobes, 
 plays a considerable part in the origin and in the course of cutaneous 
 gangrenes. 
 
 It seems logical, a priori, to group under two separate headings: 
 (1) Secondary infected gangrenes, in which a lesion or affection of 
 the skin, of definite character (wounds, ecthyma, furuncle, erysipelas, 
 pemphigus, varicella, zona, syphilide, soft chancre, etc.), becomes 
 gangrenous through the effect of an excessive virulence of its causa- 
 
CUTANEOUS GANGRENE 317 
 
 tive agent, a diminished resistance of the organism, or the introduc- 
 tion of necrotizing germs from the outside; (2) primary infectious 
 gangrenes, resulting from microbic embolism in the skin by the 
 hematogenous route. Sometimes, the direct examination of the 
 patient or the history will show at first sight that the case belongs 
 to one or the other of these groups; in other instances, there remains 
 a doubt. 
 
 There is little advantage in dwelling upon the secondary or acci- 
 dental infectious gangrenes. I shall therefore discuss only those 
 which are primary and essential; leaving aside, of course, the gan- 
 grenes of the classified general diseases, such as anthrax, bubonic 
 plague, etc., and discussing instead the clinical forms of dermato- 
 logical character. 
 
 Multiple Gangrene of Children. — This is a somewhat unusual 
 clinical type, comprising positively dissimilar forms, such as those 
 cases which have been described under the names of multiple 
 cachectic gangrene of the skin (O. Simon and Eichhof), gangrenous 
 dermatitis of children, gangrenous varicella, gangrenous ecthyma, 
 gangrenous urticaria, purpura fulminans, etc. 
 
 Instances have been observed in very young children, especially 
 girls, and in weakened individuals. Sometimes, the impression of 
 a special disease is conveyed; in other cases, one is apparently con- 
 fronted with an extraordinarily malignant form of an exanthem 
 (varicella, vaccinia, measles) or of a pseudo-exanthema (purpura, 
 polymorphous erythema) . 
 
 In a few days, a more or less abundant eruption of erythematous, 
 urticarial or purpuric spots makes its appearance, or there may be 
 bullae containing a reddish serous fluid, or pustules, which enlarge 
 and multiply. Their center very promptly turns black; the slough, 
 concealed or not by a crust, spreads more or less, then becomes 
 surrounded by a suppurative groove and loosens, leaving a per- 
 pendicular or dome-shaped ulceration with a sanious floor. The 
 coalescence of several lesions gives rise to festooned patches. The 
 sloughing may destroy a portion of the nose, of the lips, of the lobe 
 of the ear, of the external genitals, or of the fingers and toes. Nodosi- 
 ties, edemas and abscesses may also be met with. 
 
 The eruption is situated especially on the lower portion of the 
 trunk and on the thighs; it has another site of election on the neck, 
 on the scalp, and on the face; but it may be widely disseminated. 
 
 The general symptoms are of very variable severity, sometimes 
 only slightly marked; but often the condition is associated with a 
 high fever, digestive disturbances, prostration, convulsions, as well 
 as visceral complications leading to death; the mortality is about 
 50 per cent. In favorable cases, recovery is rapid. 
 
 Numerous pyococci and bacilli have been held responsible. In 
 
318 
 
 ULCERATIONS AND ULCERATIVE DERMATOSES 
 
 the carefully studied case of Veillon and J. Halle, the pathogenic 
 agent was the bacillus ramosus; it is probable that other anaerobic 
 microbes may produce analogous phenomena. Recently a few eases 
 could be referred to the meningococcus. 
 
 Multiple Gangrene of Adults. No discussion is here called for of 
 the gangrenes with multiple foci, accompanied by abscesses and 
 gangrenous phlegmons, which occur in rare instances in the course 
 of pestilential diseases, very advanced cachexias and severe diseases 
 of the nervous system. These arc cases of septic embolisms with 
 anaerobic microbes, of genuine metastases, derived from a bed-sore 
 or a gangrenous focus of any kind, especially a pulmonary gangrene. 
 
 Fig. ids 
 
 Multiple gangrene of adults; of filteen days' standing, in a man aged 
 seventy-one years in good health. 
 
 However, gangrenous eruptions entirely analogous to those of 
 children, are also encountered in youthful individuals, in good 
 health or slightly weakened and even in adults of middle age. They 
 have the same onset, the same local symptomatology, the same 
 genera] symptoms ami develop in successive attacks. Examples 
 have been quoted by Doutrelepont, Hallopeau, Carle, Brocq. 1 
 have personally observed several rather dissimilar cases, some with 
 multiple patches limited to a single region (Fig. ION), others with 
 very numerous lesions scattered over the entire integument. The 
 prognosis is grave, although not necessarily fatal. Mention has been 
 made of possible contagiousness 1 1 >emme). 
 
CUTANEOUS GANGRENE 319 
 
 Fulminating Gangrene of the Genital Organs. — A. Fournier has 
 pointed out a rare type of gangrene, observed especially in young 
 adults, leading to grave mutilations, sometimes to death. 
 
 Usually as the result of a slight excoriation, there suddenly 
 develops, without paraphimosis, an enormous rose-colored edema 
 of the penis and scrotum, with chills, high fever, etc. At the end 
 of twenty-four to thirty-six hours, the penis after having assumed 
 the appearance of a large "clapper," presents purplish, black or 
 white gangrenous patches, which may destroy the entire sheathes, 
 often the scrotum and rarely the corpora cavernosa; the swelling- 
 subsides at the end of about a week. 
 
 A very virulent streptococcus has been found in the serous dis- 
 charge. These are probably cases of gangrenous erysipelas. 
 
 Treatment. — All cutaneous gangrenes are difficult to treat. 
 Hygiene and general medications must not be too much relied on; 
 even in the cases of diabetic gangrene, where a strict diet is impera- 
 tive, this cannot prove sufficient by itself alone. 
 
 Locally, it is essential to supervise scrupulous cleanliness and well- 
 applied protective dressings. In some cases, moist aseptic dressings 
 are useful, or the application of dilute peroxide water, or even pro- 
 longed local baths; but as a rule, dry or oily dressings are preferable. 
 Dressings with strong antiseptics are frequently injurious. 
 
 The parts may be swabbed with camphorated alcohol, or with a 
 weak solution of potassium permanganate, followed by wrapping 
 in dry sterilized cotton; or large quantities of aseptic or weakly 
 antiseptic powders may be used (quinine, iron subcarbonate, der- 
 matol, iodoform). Oily dressings, with carron-oil, guaiacolized oil, 
 etc., are often better liked and seem to act more favorably. 
 
 When the gangrene is progressive it may be of vital importance to 
 destroy the focus of putrefaction and the neighboring zone of inva- 
 sion. This is accomplished by applications of superheated air in 
 jets under pressure; this requires special apparatus, experience and 
 skill, but actually constitutes the best treatment against extensive 
 gangrenes, diabetic as well as others. The hot-air method is prefer- 
 able to surgical removal, which will only be called for after the proc- 
 ess has been checked, for the resection of sequestra or the trimming 
 of stumps. 
 
CHAPTER XVI. 
 DYSCHROMIAS. 
 
 Cutaneous Pigments. — The human skin is normally pigmented 
 throughout; in this respect, there are merely differences in degree 
 between the white race and the colored races, between the different 
 regions of the body and between individuals of the same race. 
 
 The physiological cutaneous pigment consists of extremely small 
 brown or black grannies of an organic substance named melanin, 
 which contains no iron, but sulphur in variable proportion. The 
 melanin granules are situated in the basal layer of the epidermis 
 and, furthermore, when the pigmentation is very marked, in certain 
 cells of the papillary body; the color of the hairs and of the choroid 
 is likewise due to melanin. 
 
 Under pathological conditions, two other pigments may be met 
 with, hemosiderin, an ochre pigment which gives the reactions for 
 iron and is formed in bloody extravasates, becoming deposited 
 exclusively in the cutis; and the paludean pigment which is charac- 
 teristic of malarial melanodermia. 
 
 Except in cases which will receive special consideration, the dys- 
 chromias are due to variations in the amount of melanin. 
 
 Dyschromias. — The name "dyschromia" is applied to pathological 
 changes in the color of the skin, resulting either from an excess or a 
 deficiency of pigment. They do not disappear on pressure with the 
 finger, resist all washing, etc., and ordinarily persist a long time, 
 sometimes throughout life. 
 
 As a rule, there is an excess of pigmentation. These hyper- 
 chromias may be circumscribed, representing pigmentary spots; or 
 diffuse, representing melanodermas. 
 
 Hypochromic, and achromia are more uncommon. 
 
 When the latter is congenital, it is known as albinism; it may be 
 generalized or localized. Complete albinism, in which there is a more 
 or less total absence of pigment in the skin and its appendages, is a 
 grave degeneration, very rare in the human race. Albinos have a 
 waxy skin, white or very light colored hair on the seal]) and body 
 and ;i red or bluish iris. 
 
 Partial congenital achromia is the exact oppositeof a pigmentary 
 nevus; it is often familial, circumscribed in a nerve territory of only 
 one side of the body, or it may consist of a few white spots, known 
 as achromic nevi. 
 
ARTIFICIAL AND SECONDARY DYSCHROMIAS 321 
 
 Acquired hyperchromia is known as leukoderma and is usually 
 secondary to a local process. It is frequently associated with 
 hyperchromia at neighboring points, constituting the leukomelano- 
 dermas of vitiligo and some other analogous affections. 
 
 The causes of the dyschromias are extremely variable, and this 
 pathogenic mechanism is far from being entirely understood. 
 Among these causes, some act locally, while others are of a general 
 kind, such as intoxications, infections, changes of the blood, nervous 
 disturbances. 
 
 In both these cases, the pigmentation may assume the form of 
 more or less circumscribed spots or it may become diffused over 
 surfaces. The generalized melanodermas are always referable to a 
 general cause. In the leukomelanodermas, the intervention of a 
 nervous disturbance is usually admitted as essential. 
 
 For the diagnosis of a dyschromia it is first of all necessary to 
 ascertain : if it is secondary to another process (macules) or primary 
 or essential; if it is simple, without other changes of the integument, 
 or associated with a dermatosis of different character; if it is circum- 
 scribed (pigmentary spots) or diffuse (melanoderma), generalized or 
 regional. 
 
 The dyschromic syndromes to be discussed in the following have 
 been arranged according to this plan; a paragraph has been added 
 on the subject of vitiligo and other leukomelanodermas. 
 
 Finally, although these conditions are not due to pigmentary 
 disturbances but to foreign bodies, a few lines are devoted to 
 tattoo-marks and argyria. 
 
 ARTIFICIAL AND SECONDARY DYSCHROMIAS. 
 
 Artificial Pigmentations. — Any cutaneous irritation, especially 
 when fairly strong and prolonged, may become the origin of an arti- 
 ficial local pigmentation. Certain individuals are evidently predis- 
 posed to it and its production is favored by stasis of the blood, as 
 for example in varicose legs. 
 
 In some cases, the pigmentation is the direct and exclusive result 
 of the irritation; in others it follows upon a hyperemia or even a 
 bullous or eczematous process, etc., belonging in the last-named 
 case to what I describe as macules. 
 
 Mechanical factors, friction by the clothing, corsets, shoes, 
 bandages, repeated scratching in pruritus, give rise to hyperchromias 
 of an often characteristic seat and configuration. 
 
 Among pigmentations due to physical factors, it suffices to call 
 attention to the following: the tanned complexion produced by 
 sunlight, the open air, electric light, the a'-rays; the caloric pigmen- 
 21 
 
322 DYSCHROMIAS 
 
 tatioD of the face, forearms and trunk in blacksmiths, glass-blowers, 
 bakers, etc.; of the thighs, in out-of-doors hucksters who have the 
 habit of sitting on their foot-warmers and of any region of the body 
 in persons who have abused hot compresses <>r very hot lotions for 
 the nlicf of pain, pruritus, etc.; this is often arranged after the 
 fashion of a wide-meshed network. [The dermatitis calorica of 
 furnace men and others exposed to great heat is commonly followed 
 by this reticular pigmentation.] Many chemical agents may cause 
 very persistent pigmentations, even without a caustic action; and 
 it is well for the physician to he forewarned, so as to avoid reproach 
 under some condition-. This remark applies to nearly all rube- 
 facients and counter-irritants, notably mustard plasters, methyl 
 chloride, chloroform, tincture of iodin, etc. Applications of chrysa- 
 robiii usually give rise to a bronzed erythema, followed by an 
 extensive but temporary brownish pigmentation from which the 
 healed patches of psoriasis stand out in white. 
 
 The treatment of the artificial pigmentations consists in the 
 removal of the cause of the hyperchromia and in the employ- 
 ment of topical agents which will be discussed in connection with 
 chloasma. 
 
 Macules.- I June for a long time been accustomed to reserve 
 1 1 1 i s name, which is popularly used interchangeably with the word 
 spots, for the dyschromic but not cicatricial residues of a large 
 number of cutaneous affections. 
 
 They follow upon excoriations, upon erythematous, vesicular, 
 eczematous, bullous eruptions, such as burns, blisters from vesicants; 
 purulent bulhe of impetigo; superficial folliculitides; the multiple 
 lesions of scabies; papules of all kinds, etc. 
 
 They consist of a local, often distinctly circumscribed, pigmenta- 
 tion or sometimes of a central hypochromia surrounded by a pig- 
 mentary halo. They are often scaly at the onset and then of a 
 perfectly normal surface. 
 
 In the absence of sufficient observation or information, maculae 
 may lead to numerous errors of diagnosis. It is necessary to guard 
 against the confusion of macula?, whose epidermis has its normal 
 structure and which are always temporary, with deaf rices- which 
 are always permanent. 
 
 The seat, extent and configuration of the macules often possess 
 important indicative value in regard to the causative dermatosis. 
 The hyperchromic tendency of syphilitic papules of all kinds, in 
 certain individuals, has long been emphasized. These syphilides 
 nigricantes, to use A. Founder's term, are sometimes a source of 
 great distress for the patient. 
 
 A special group of pigmentary macules of hemorrhagic origin, in 
 which the pigment is hemosiderin, is represented by the brown 
 
PIGMENTARY SPOTS 323 
 
 spots following on traumatic or purpuric ecchymoses, hemorrhagic 
 urticaria, varicose eczema, etc. 
 
 Under the name of pigmentary dermatosis of the legs (or dermite 
 jawne d'ocre) have been separately described large more or less 
 distinctly outlined spots of a uniform brown or mottled color, which 
 are frequently observed on the legs of arteriosclerotic, varicose or 
 diabetic individuals, or in Bright's disease, etc., and which persist 
 indefinitely. They result from minute interstitial frequently repeated 
 hemorrhages. 
 
 ASSOCIATED DYSCHROMIAS OR DYSCHROMIC DERMATOSES. 
 
 Several dermatoses give rise to a black or dark coloration of the 
 integument which is not dyschromic, in so far as it results exclusively 
 from an abnormal hue of the horny layer. In such cases, the colored 
 layer can be finally detached by energetic scratching. This occurs 
 in many hyperkeratoses and keratodermas, in ichthyosis niger, in 
 psorospermosis follicularis, in certain seborrheas nigricantes, in 
 pityriasis versicolor, in the carates [pinta], etc., and to a less degree, 
 in kerosis. 
 
 Some dermatoses are actually pigmentary anomalies or may 
 lead to such. Spots from antipyrin and from leprosy are, as a rule, 
 ery themato-pigmented . 
 
 Various eruptions will be mentioned further on, which may be 
 accompanied by a sort of pigmentary ataxia, such as lichen planus, 
 various prurigos, etc. 
 
 Pigmentations also form an essential part of the pathological 
 disturbances of acanthosis nigricans, xeroderma pigmentosum and 
 several analogous cutaneous dystrophies; of v. Recklinghausen's 
 disease and urticaria pigmentosa. 
 
 The reader is finally reminded of the pigmentary tumors, malig- 
 nant, such as the nevo-carcinomata or pigmented sarcomas; or 
 benign, such as pigmented nevi. 
 
 In this entire group of associated dyschromias, it is the underlying 
 dermatosis, characterized by its peculiar lesions which establishes 
 the diagnosis, governs the prognosis, determines the treatment and 
 explains the pigmentation. 
 
 PIGMENTARY SPOTS. 
 
 Ephelides. — Ephelides, or freckles, confused by some derma- 
 tologists with lentigo, are small lenticular, rounded or oval, more 
 rarely irregular spots, of a light yellow, cafe-au-lait or brownish 
 color, perfectly flat, smooth and not scaly, generally isolated and 
 numerous, or very profuse and agminated if not confluent, sym- 
 metrically arranged, having their seat of predilection on the face, 
 
324 DYSCHROMIAS 
 
 the nose, the prominences of the cheek bones, the forehead, the 
 hands and forearms. More rarely, they are scattered over the 
 shoulders, the arms, the legs, the buttocks and the genitals. 
 
 Ephelides are not congenital, but appear during childhood and 
 youth, especially in blond or red-haired, anemic or lymphatic indi- 
 viduals and in persons enjoying excellent health. 
 
 Sunlight undoubtedly plays a considerable part in the mechanism 
 of their onset, as suggested by their name; also, they are much more 
 apparent during the spring and summer than in winter. But on 
 the other hand, they are plainly hereditary or atavistic in certain 
 families; they develop also in covered regions of the body and are 
 in every way comparable to nevi. 
 
 The histology of ephelides shows merely an abnormal quantity of 
 pigment in the basal epidermic cells, with presence of pigmentary 
 cells in the papillary body. 
 
 Chloasma. — Chloasma uterinum consists of spreading spots, 
 irregular in shape and outline, sometimes confluent in patches, of a 
 yellow, brownish, or still darker color, situated almost invariably 
 symmetrically on the forehead, the temples, the lateral portions of 
 the cheeks and more rarely on the eyelids, the chin, or at other 
 points of the body. The well-marked outline of chloasma dis- 
 tinguishes it from the caloric and solar pigmentations. 
 
 Chloasma ordinarily develops in pregnant women and persists 
 until the reestablishment of menstruation and often throughout 
 life. At the same time, or even in its absence, there appears a pig- 
 mentation of the linea alba, the areola of the nipples and the vulva, 
 especially in brunettes. Various pathological conditions, metritis, 
 salpingitis, dysmenorrhea, etc., may produce identical pigmenta- 
 tions. Cases of chloasma without a demonstrable cause are also 
 met with. 
 
 It seems probable to me that an irritation of the abdominal 
 sympathetic nervous apparatus enters into its pathogenesis, as in 
 the case of Addison's disease [and probably in acanthosis nigricans.] 
 
 The treatment of chloasma, like that of the ephelides and arti- 
 ficial pigmentations, yields no satisfactory results. Prophylactic 
 measures would be the most advisable, with avoidance in predis- 
 posed persons, of cutaneous irritation or exposure to light; suitable 
 treatment of uterine and abdominal affections or anemia and the 
 lymphatic constitution when present. The administration of 
 arsenic, which produces hyperchromia, is contra-indicated. 
 
 Locally, so-called decolorizing washes may be prescribed, appli- 
 cations of mercurial plasters during the night, or salicylated calomel 
 partes, or some peroxide cream. Exfoliation by means of exfoliating 
 pastes is often successful in decolorizing the hyperchromic surfaces, 
 but the cure is as a rule merely temporary. 
 
DIFFUSE DYSCHROMIAS AND MELANODERMAS 325 
 
 Disseminated Pigmentary Spots. — As has just been shown, the 
 ephelides and chloasma are regional affections. In the presence of 
 disseminated yellow or brownish pigmentary spots, or a single spot, 
 it is necessary to think in the first place of the artificial, macular 
 and secondary pigmentations which have been discussed in the 
 preceding paragraphs; next, of the pigmentary nevi and of v. Reck- 
 linghausen's disease, which includes some abortive forms, exclu- 
 sively pigmentary; finally, one must keep in mind the possibility 
 of circumscribed pigmentations in several melanodermas due to 
 general causes. 
 
 The blue or shaded spots produced by the bite of phthirius 
 inguinalis or the crab-louse, are characterized by their peculiar 
 slate-blue coloring. They are of irregular form, of lenticular or 
 nummular dimensions; the epidermis is in no way changed; they 
 cause no itching and are of ephemeral duration [up to a week or 
 more]. They are situated in variable numbers on the abdomen, 
 the thighs, the back, and sometimes on the chest. The experiments 
 of Duguet have shown them to be due to the local action of the 
 venom of the parasite. 
 
 DIFFUSE DYCHROMIAS AND MELANODERMAS. 
 
 Diffuse pigmentations, whether generalized or, what is more 
 common, regional or with regional predominance, are referable to : 
 chronic infections, such as tuberculosis, syphilis, leprosy and pellagra ; 
 or to intoxications, such as arsenicism and phthiriasis; or to a variety 
 of blood diseases; or to diseases of the nervous system. Occasionally, 
 leukoderma is intermingled with hyperchromia. 
 
 Addisonian and Tuberculous Melanodermas. — In Addison's dis- 
 ease, the bronzed coloration of the integument is often delayed; 
 but. it may also precede by several years the other symptoms, such 
 as asthenia, digestive disturbances and lumbar pains. The pig- 
 mentation, which is diffuse, of a red-brown or gray-brown color, 
 first involves and stains the genital organs, the areolae of the 
 breasts, the articular folds and the uncovered portions, face and 
 hands, and long-standing or recent scars. Jacquet has shown that a 
 local irritation may "externalize" a latent tendency to pigmenta- 
 tion. On the hyperchromic surfaces, normal areas simulating 
 leukodermic spots are sometimes seen. 
 
 Very commonly the pigmentation involves also the buccal mucosa, 
 where tan or brownish spots, distinctly outlined or with diffuse 
 margins, are noted on the cheeks, the lips, the tongue, the gums 
 and the palate. [Pigmentation of the mucosa sometimes precedes 
 that of the cutaneous surface.] The cutaneous and mucous lesions 
 consist of an excess of melanin in the epidermis and cutis. 
 
326 DYSCHROMIAS 
 
 The melanoderma of Addison's disease is now known to be 
 referable, not so inneh to a change of the suprarenal bodies them- 
 selves as to a lesion or irritation of the pericapsular sympathetic 
 nerve apparatus which apparently presides over the regulation of 
 the pigment. It has occurred to me that the pigmentations of 
 acanthosis nigricans, of chloasma and perhaps that of pigmentary 
 syphilides, may have an analogous pathogenesis. 
 
 The melanoderma of tuberculous patients has long been known, 
 especially in cases of tuberculous peritonitis or enteritis. It con- 
 sists of a dusky or brownish coloring of the genitals, the abdomen 
 and sometimes the neck. It evidently results from the same condi- 
 tions as genuine Addison's disease, from which it differs as a rule 
 only by its more limited diffusion especially on uncovered parts. 
 
 Pigmentary Syphilides. — Aside from the posteruptive pigmentary 
 macules referred to before and the tertiary leukomelanodermas to 
 be discussed further on, syphilis very frequently produces a truly 
 specific areolar pigmentation of the neck, which ranks among its 
 most significant symptoms. 
 
 This areolar pigmentary syphilide is more common in women 
 than in men. It appears as early as the second or third month, or 
 in the course of the first year, rarely after two years and has a very 
 indefinite duration which it is very difficult to determine [five to 
 fourteen months, according to Jadassohn]. It consists of a grayish 
 or brownish more or less dark hyperchromia, with diffuse borders, 
 interspersed with islands of distinctly outlined white spots varying 
 in size from a lentil to a franc, so that the whole forms a network 
 with large strands, usually better marked on the lateral portions 
 of the neck (Fig. 109). This "necklace of Venus" may send radiat- 
 ing processes on the chest, often in front of the axilla 1 , on the flanks, 
 or still farther. In some cases, pigmentary macules are found in the 
 center of a few of the white areola 3 . 
 
 The pathogenesis of areolar syphilide is still a matter of contro- 
 versy. By some, the pigmentation is interpreted as the primary 
 and exclusive feature, the apparent decoloration of the meshes being 
 referable to a contrast-effect; others assume true leukodermic patches, 
 following upon a sometimes not very evident eruption, which become 
 secondarily surrounded by hyperpigmented areas. 
 
 It is more than probable that both these interpretations are 
 correct in different cases and that there are really two modes of 
 formation of the pigmented network. 
 
 This dyschromia is almost pathognomonic. However, a few old 
 observations are on record of areolar pigmentations of the same type 
 referable to tuberculosis and chlorosis; these date back, it must be 
 noted, to a period prior to the discovery of the serodiagnosis of 
 syphilis. 
 
DIFFUSE DYSCHROMIAS AND MELANODERMAS 327 
 
 Inversely, pigmentations of another type, analogous to chloasma, 
 for example, have been noted in secondary syphilis. 
 
 The syphilitic hyperchromias are practically not amenable to 
 specific treatment. 
 
 Fig. II 
 
 -Areolar pigmentary syphilide of the neck. (After a east in the Museum 
 of the St. Louis Hospital.) 
 
 Dyschromias of Leprosy. — The initial erythemato-pigmented 
 spots, leprous pemphigus, tubercles, infiltrations and ulcers often 
 leave behind them hyperchromic or plainly achromic spots, or 
 leukomelanodermas resulting from a combination of these two 
 opposite disturbances. 
 
 For instance, white spots with a pigmented border may be 
 observed — annular, band-like, or diffuse, or dark surfaces dotted 
 with colorless spots, etc. 
 
 All these various manifestations, which were formerly designated 
 under the names of melas, leuke, morphea alba et nigra, vitiligo 
 gravior, are usually characterized by anesthesia. 
 
 The distribution of the pigment is variable. Hansen's bacilli are 
 almost regularly demonstrable in sections of the skin, although in 
 very small number. 
 
 Dyschromias of Nervous Diseases. — In the organic diseases of 
 the nervous system, the disturbances of pigmentation are usually 
 not pronounced. 
 
 In hemiplegia, cerebral tumors, infantile paralysis, progressive 
 muscular atrophy, syringomyelia, tabes, the traumatic or toxic 
 neuritides, etc., slight modifications in the coloring of the skin have 
 been reported, associated with other trophic disturbances, hyper- 
 trichosis or alopecia, hyperidrosis, etc. The same observations have 
 been made in mental diseases of the depressive or melancholic type. 
 
328 DYSCHROMIAS 
 
 On the contrary, the dyschromias are abundantly represented on 
 the borderland of nervous pathology, in diseases placed here by 
 their symptoms. In Raynaud's disease, in myxedema, in exoph- 
 thalmic goitre, they are of frequent occurrence; vitiligo is rather 
 common in Graves' disease. 
 
 In scleroderma under its different aspects, which can hardly be 
 considered simply a nervous disease and in facial hemiatrophy, 
 which is related to it in some respects, hyperchromia is a nearly 
 constant symptom. A more or less deep, diffuse, areolar or spotted, 
 primary or delayed pigmentation is noted, occupying the sclerotic 
 areas, or the neighboring regions, or sometimes a large extent of 
 the integument. Depigmentation of the sclerotic patches or regions 
 i- also not uncommon. 
 
 Dyschromias in Diseases of the Blood and in Cachexias. — It is 
 enough to mention the hypochromia which may be seen in chlorosis, 
 the chloro-anemias, pernicious anemia, the leukemias and in cancer- 
 ous cachexia. 
 
 Inversely, it is not exceptional to observe various diffuse or 
 regional melanodermas in these diseases more particularly in Banti's 
 disease and in the psendo-leukemias. 
 
 The melanoderma of bronzed diabetes, with or without pigment- 
 ary hypertrophic cirrhosis, is generalized, almost invariably spares 
 the mucous membranes and consists of an infiltration into the cutis 
 as well as other tissues, of an ochre-colored pigment known as rubigin. 
 
 In malarial cachexia, the coloration is ashy, a dirty gray, or yellow 
 gray, diffusely and uniformly distributed. The malarial pigment, 
 which is specific, is derived from the malaria-parasites, is carried to 
 the skin by the blood (melanemia), and is here deposited, associated 
 with an ochre pigment of hemic origin [hemosiderin]. 
 
 Arsenical Dyschromias. — Arsenical melanoderma may develop 
 independently of the age and sex of the patient or the nature of the 
 arsenical remedy and its mode of introduction. Very minute doses 
 are sometimes sufficient for its production, although as a rule, a 
 prolonged absorption, medicinal, occupational, or accidental, is 
 responsible. 
 
 The pigmentation may assume two forms which are sometimes 
 combined; that of diffuse hyperchromia predominating in normally 
 colored areas, cicatrices, or cutaneous regions which are subject 
 to pressure, or that of pigmentary spots, which enlarge and become 
 confluent. In patients who have been improperly treated with 
 arsenic for psoriasis or lichen, a very deep generalized melanoderma 
 is sometimes observed. 
 
 The coloration is iron-gray, bronzed, or even black. The 
 uncovered regions remain relatively free, as well as the mucous 
 membranes, with very rare exceptions. 
 
VITILIGO 329 
 
 Pediculous or Phthiriasic Melanoderma. — In paupers, tramps, 
 scavengers and rag-pickers living in filth and misery, exposed to all 
 sorts of vermin and whose clothing sometimes harbors incredible 
 numbers of pediculi corporis, this condition is known to occur, 
 so that the name of Vagabond's disease is usually entirely justified. 
 
 The pigmentation, of a dirty brown mottled with excoriations, 
 crusts and cicatrices, predominates on the back, the nape of the neck, 
 the shoulders, the waistline, and the thighs; but it may spread all 
 over the integument, including the face and the extremities. 
 
 Thibierge has shown, and I was repeatedly enabled to verify the 
 fact, that the pigmentation is observed even on the buccal mucosa, 
 in the form of spots resembling those of Addison's disease. 
 
 The hyperchromia has been attributed to scratching, to bloody 
 extravasations and to the local action of the venom of the lice. 
 Its generalization and its possible localization in the mouth, show 
 that this poison has a systemic action. The asthenia, the often very 
 cachectic appearance of the patients, and the digestive disturbances 
 from which they suffer, are additional proofs of this contention and 
 help to render the differential diagnosis from Addison's disease very 
 difficult in some cases. 
 
 VITILIGO. 
 
 Vitiligo is a non-congenital dyschromia characterized by the 
 appearance of achromic or strongly hypochromic white spots, which 
 are sharply limited and surrounded by a more or less extensive zone 
 of hyperpigmentation. 
 
 Aside from the change in color, the skin presents no alteration 
 of its surface, consistence or function. 
 
 The white spots of vitiligo have a milky or ivory hue, a dull 
 sheen, a generally round, oval, or polylobular form, distinct faintly 
 sinuous outlines. Sometimes they are in small numbers, but in 
 other cases they may be so profuse and numerous as to cover a 
 large portion or nearly the whole of the integument (Fig. 110). 
 
 The hyperchromia of the intermediate regions, which have a 
 brown or grayish hue, is often particularly marked at the very 
 border of the white spots; this arrangement conveys the impression 
 of the pigment having been pushed out from the achromic surfaces. 
 At the periphery of the hyperpigmented zones, the transition into 
 the normal color is gradual and imperceptible, rarely marked by a 
 distinct boundary. 
 
 The down and hairs of the white spots are either entirely colorless 
 or of normal color. 
 
 The dyschromia is associated with no sensory disturbance, neither 
 pain, nor itching, nor noteworthy anesthesia being demonstrable. 
 
 Jadassohn points out that the white spots are more susceptible 
 

 DYSCHROMIAS 
 
 to solar erythema, while they arc on the contrary more resistant 
 to various cutaneous irritations and relatively immune to certain 
 eruptions. 
 
 The topography of vitiligo is extremely variable, not infrequently 
 its distribution is more or less symmetrical. It may occupy any 
 region, although it show- a certain predilection for the back of the 
 hands, the wrists and the forearms, the face and neck and for the 
 genital organs and the neighboring areas. The mucosas are always 
 intact. 
 
 The course of the affection i- governed by no rule; it may appear 
 suddenly or more often insidiously; it- extension i- gradual and 
 almost imperceptible or sometime- occurs in successive attacks. 
 
 f « Ji 
 
 Hi*- r 
 
 
 110.— Vitiligo. 
 
 The dyschromia may remain almost stationary, with seasonal 
 variations of its shade-; more commonly, the white spot- spread 
 and become confluent in patches; they may even become generalized; 
 Inn at the same time the degree of the hyperchromia diminishes. 
 A complete cure is very rare. 
 
 The etiology of vitiligo is unknown. Adolescence, youth and the 
 female sex seem to be relatively predisposing. It has been known 
 to occur in persons who had been exposed to a nervous or emo- 
 tional shock. Repeated traumatisms certainly play a part, for 
 vitiligo is not rare at point- exposed to friction a-, for instance, 
 from a hernial truss. 
 
 Moreover, it becomes associated too frequently for a merely 
 
SECONDARY LEUKODERMAS AND LEUKOMELANODERMAS 331 
 
 accidental combination, with alopecia, circumscribed prurigos, 
 lichen planus, scleroderma and with a variety of nervous diseases, 
 notably tabes dorsalis and exophthalmic goiter. 
 
 Like several writers, I have been struck with the relative fre- 
 quency of syphilis in patients with vitiligo; however, there is at 
 present no reason for admitting the existence of a syphilitic vitiligo, 
 nor especially that all vitiligo depend upon this infection. 
 
 The pathological anatomy shows the almost complete disappear- 
 ance of the pigment in the leukodermic spots and its abundance 
 on the contrary in the epidermis and derma of the hyperchromic 
 regions; but it affords no information as to the pathogenesis of 
 these lesions. 
 
 The diagnosis is very easy in the vast majority of the cases. An 
 even cursory examination suffices to guard against confusion with 
 pityriasis versicolor and with the various pigmentations, circum- 
 scribed or diffuse, but without achromic spots, which have been 
 mentioned in the course of this chapter. The light areolas of the 
 pigmentary syphilide of the neck, which is moreover characterized 
 by its seat, as well as those which may eventually be encountered 
 in various melanodermas, are usually preserved normal skin areas 
 and not leukodermas. 
 
 The only real difficulties which may present themselves are the 
 following: In the course of leprosy, pigmented surfaces and 
 achromic spots have been demonstrated and as a whole have been 
 designated as vitiligo gravior; very evident sensory disturbances are 
 present in these cases. 
 
 In certain families of temperate zones and more frequently in 
 the colored races, congenital leukomelanodermas or cases of partial 
 albinism have been noted ; the dyschromia in these cases is absolutely 
 stationary and sometimes symmetrical. So-called piebald negroes 
 are probably in part referable to this congenital anomaly and in 
 part to vitiligo or to leprosy. 
 
 The treatment of vitiligo usually is not very effective. In those 
 cases where syphilis seems to be involved, or in the coexistence 
 of tabes, mercurial treatment should be administered and I have 
 obtained a remarkable success in one instance. It is to be 
 feared that arsenic may aggravate the hyperchromia. As a rule, 
 nothing can be done but to regulate the patient's general hygiene, 
 to prescribe sedative or tonic hydrotherapy and electric treatments. 
 Various opotherapies might be indicated in this affection. The 
 overpigmented zones may be treated with the customary decolorizing 
 agents. 
 
 Secondary Leukodermas and Leukomelanodermas. — These are 
 distinguished from vitiligo by this essential characteristic that the 
 dyschromia here is not simple, but accompanies an eruptive mani- 
 
332 DYSCHROMIAS 
 
 festation, or a change in the thickness, consistence and structure 
 of the skin. 
 
 There is a coexisting eruption, with disturbances in pigmentation, 
 in lichen planus, lichen hypertrophicus, circumscribed prurigo, etc. 
 
 There is sclerosis or atrophy of the skin in the following cases: 
 the leukodermic spots of circumscribed scleroderma, also known as 
 morphcea nostras, which are bordered by a lilac ring; the morphcea of 
 lepras)/ which is anesthetic and contains Hansen's bacillus; the 
 cutaneous atrophies in patches, often preceded by an erythematous 
 stage; lichen planus- atrophicus which has been papular; sclerotic 
 radiodermatitis, which is interspersed with telangiectases. 
 
 Cicatrices, no matter of what origin, as well as linear atrophies 
 are sometimes pigmented or leukodermic and in the latter case 
 often surrounded by a zone of hyperchromia. This is of especially 
 common occurrence in the cicatrices of tertiary syphilis. Under 
 the name of syphilitic leukomelanodermas, extreme cases have been 
 described, by A. Fournier, Gemy, etc., in which the skin finally 
 becomes mottled with black spots, or sometimes with rounded or 
 polycyclic white spots in the midst of pigmented surfaces, so as to 
 simulate vitiligo from a distance. 
 
 TATTOO MARKS AND ARGYRIA. 
 
 Tattoo marks are spots on designs produced by the deliberate 
 introduction of colored and insoluble particles into the cutis where 
 they persist indefinitely. 
 
 These more or less artistic tattoo marks and inscriptions are 
 usually made with lamp black or India ink when they are blue, or 
 with vermilion when they are red; the colored powder is made to 
 penetrate by means of closely bunched very fine needles. Tattoo 
 marks are commonly seen in sailors, colonial soldiers, prostitutes 
 and their cadets; but also occasionally in the educated classes, as 
 the effect of a peculiar aberration. 
 
 Powder spots, resulting from a gunshot fired at close range and 
 from the penetration of bits of charcoal, have a characteristic 
 arrangement. 
 
 In certain occupations, among grinders, filers, stone-breakers, 
 miners, etc., particles of steel, Mint, or coal, may penetrate into the 
 cutis and cause a sort of occupational tattooing. 
 
 Electrolysis, or hypodermic injections applied with steel needles, 
 may likewise leave prints of siderosis. 
 
 Argyria is a slaty coloration, with bluish reflexes, which develops 
 in persons exposed to the prolonged absorption of silver nitrate 
 pills or other silver salts. It is generalized, but much more pro- 
 
TATTOO MARKS AND ARGYRIA 333 
 
 nounced on the face, the hands and the articular folds and may also 
 affect the mucous membranes. 
 
 The silver granules, conveyed by the bloodstream, impregnate 
 especially the elastic fiber and the capillaries, sparing the cellular 
 elements. 
 
 Spots of local argyria may be encountered on the buccal, con- 
 junctival and vulvar mucosa?, following upon energetic cauteriza- 
 tions with lunar caustic. [Very distressing cases of local and even 
 quite extensive argyria have followed the use of the organic silver 
 compounds in the treatment of dachryocystitis.] 
 
 Treatment. — In order to remove tattoo-marks, which is difficult, 
 various caustic agents may be used. Variot recommends retattooing 
 with a concentrated solution of tannin and then passing a silver 
 nitrate pencil over the surface. A dry slough is formed, which 
 brings the tattoo mark away with it, provided the slough is deep 
 enough. I have advantageously employed crossed linear scarifica- 
 tion followed by cauterization with pure carbolic acid. Applica- 
 tions of carbonic acid snow have also been recommended. 
 
CHAPTER XVII. 
 
 CUTANEOUS ATROPHIES, SCLEROSES AND 
 DYSTROPHIES. 
 
 Cutaneous atrophy is a nutritional disturbance of the skin in which 
 there is a diminution in the number or volume of its constituents, 
 the clastic tissue in particular; clinically, it manifests itself as a 
 diminution of the actual thickness or consistence of the integument. 
 The atrophic skin is therefore more supple, more easily folded and 
 often thinner than the normal skin, its color is usually altered, 
 either pinkish or of a pearly white. Sometimes, as in certain linear 
 atrophies, for instance, the skin seems to he thickened on inspection, 
 while remaining soft, depressible and easily folded; this depends 
 upon its relaxation and infiltration by plasma, or upon the atrophied 
 portion being pushed out, as it were, by the tension of the normal 
 and more resistant integument of the vicinity (see Fig. 111). 
 
 Cutaneous .sclerosis is a condensation of the skin-components, 
 which may or may not be increased in size and number, but are 
 always more heaped tip and move less readily over each other. 
 The sclerotic skin may therefore be thickened or normal or even 
 thinned; in the latter case it seems to be atrophic; but it is always 
 more firm, less depressible, generally difficult to fold and often it is 
 adherent to the subjacent tissues. 
 
 Although atrophoderma and dermatosclerosis constitute different 
 and in some respects opposite conditions, they are sometimes 
 difficult to distinguish clinically; they are often combined or asso- 
 ciated or follow one another, so that it is advisable to study the 
 syndromes in which they are met with in the same chapter. 
 
 Finally, there exist alterations of the skin which can hardly be 
 designated otherwise than as cutaneous dystrophics. The integu- 
 ment here is sometimes thinned, in other cases swollen, while its 
 consistence is usually diminished. They form a natural group 
 which logically takes its place by the side of the preceding. 
 
 The pathogenesis of these atrophies, scleroses, and dystrophies is 
 sometimes evident, often on the contrary very obscure and cer- 
 tainly not uniform. Sometimes they arc congenital and represent 
 actual malformations (example: atrophic nevi, xeroderma pigmen- 
 tosum); in other cases they behave like degenerations due to old 
 age, repeated exogenic or endogenic irritations; again, they are 
 secondary to a more or less definite inflammatory or neoplastic 
 
SCLEROTIC AND ATROPHIC DERMATOSES 335 
 
 process, of which they constitute a necessary or possible residue; 
 or finally they seem to be primary or idiopathic, supervening with- 
 out apparent cause and without being preceded by demonstrable 
 lesions, so that their etiology and their mechanism altogether 
 escape us. 
 
 Sometimes a relation may be observed between the dermatosis 
 and some disturbances of the general health, but this is entirely 
 absent in other cases. 
 
 Sclerotic and Atrophic Dermatoses. — The reasons for studying 
 these together have just been stated. Practically, the two are 
 inseparable. My object here is not to establish absolutely logical 
 groups from the standpoint of general pathology, but to present 
 clinical pictures conforming as closely as possible to actual facts. 
 
 The atrophies and scleroses are deuteropathic or idiopathic. 
 
 1. The deuteropathic, generally diffuse forms, with or without 
 sclerotic retraction of the skin, following upon various grave 
 dermatoses — pityriasis rubra of Hebra, malignant herpetides, con- 
 genital pemphigus, some cases of pemphigus foliaceus — will not be 
 commented on. The atrophy here is merely an epiphenomenon and 
 the dermatoses in the course of which they occur have been described 
 elsewhere (Chapters VI and X) . 
 
 2. Other scleroses or atrophies, likewise deuteropathic, are 
 entitled on the contrary to special consideration; they are sequelae 
 of lesions or of circumscribed dermatoses, persisting long after the 
 causative affection, which can sometimes be retrospectively recog- 
 nized through them. These are the cicatrices and cicatricial atrophies. 
 
 3. Next to them I place the linear or macular atrophies, a hetero- 
 geneous group of atrophies of variable pathogenesis, comprising 
 protopathic forms and others which are deuteropathic. 
 
 4. A description of the idiopathic atrophies will follow. These 
 curious and interesting affections are as yet imperfectly defined 
 and their etiology is unknown. A distinction is made between 
 diffuse or regional forms and other macular and disseminated forms. 
 
 5. Congenital atrophies are very rare. A generalized form has 
 been observed in degenerates, the offspring of parents tainted by 
 alcoholism, tuberculosis, syphilis, etc. Their integument is thin, 
 smooth, allowing the vessels of the hypoderm to shine through, 
 pale or variably pigmented, and extremely vulnerable. Partial 
 congenital atrophies, or atrophic nevi, are more or less distinctly 
 outlined spots of the same appearance, or yellowish and prominent 
 through hypertrophy of the hypoderm; they may assume a zoniform 
 arrangement. 
 
 6. I shall finally discuss the sclerodermas, diffuse and circum- 
 scribed scleroses in the true sense of the term and which are still 
 regarded as idiopathic. 
 
336 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 7. In another paragraph will be united a few regional dermato- 
 scleroses which notwithstanding the analogy of their lesions, a 
 mixture of atrophy and sclerosis, differ from each other by their 
 localization, their course and probably by their pathogenesis. 
 
 Cutaneous Dystrophics. — This denomination would fit a con- 
 siderable number of chronic dermatoses: Cutaneous atrophies, 
 scleroses and hypertrophies, many keratoses, dyschromias, folli- 
 culosis, trichoses and onychoses, etc., really resulting from a nutri- 
 tional disturbance of the tissues of the skin. I shall limit myself 
 to grouping under this heading: xeroderma pigmentosum, senile de- 
 generation, presenile dystrophy, and finally two rare degenerations: 
 pseudo-xanthoma and colloid milium. 
 
 CICATRICES. 
 
 A cicatrix consists of newly developed tissue which has replaced 
 a loss of substance or followed an inflammatory process. This 
 new tissue is always fibrous; moreover, the reconstruction of the 
 skin always remains imperfect for there is a lack of elastic tissue, 
 smooth muscle fibers, hairs and cutaneous glands, often even of the 
 papillary body. A cicatrix may therefore be said to be at the same 
 time a deuteropathie dermatosclerosis and a cutaneous atrophy, 
 even when the scar itself is hypertrophic. 
 
 A good cicatrix is smooth, level or slightly depressed, pink or 
 white in color, supple and movable on the underlying tissues. A 
 vicious cicatrix is uneven, salient or furrowed by retracted bands; 
 a keloid cicatrix is the seat of a prominent and hard fibrous hyper- 
 trophy. 
 
 Very superficial cicatrices are recognized only by a very trifling 
 depression and a somewhat glistening sheen, with an altered "grain" 
 of the skin, sometimes with dilatation of the follicular orifices; 
 these changes being absent in simple macules. 
 
 Thicker cicatrices are at first rose-colored, ultimately white or 
 pigmented, sometimes scaly and usually firm on touch. Being less 
 extensible, less elastic than the healthy skin and often provided 
 with a less active blood supply, they are liable to become the seat 
 of tears and cracks, or they may be so highly vulnerable that slight 
 traumatisms may give rise to serous or hemorrhagic bullae or 
 maintain ulcers in the scars; sometimes they are tender or even 
 spontaneously painful. It is readily understood that when the 
 causative lesions have involved the deep parts, bones, muscles, 
 tendons, etc., the cicatrices may be adherent. 
 
 The origin of cicatrices is extremely variable. From this view- 
 point they may be divided into three groups: 
 
 J. Those which are due to an artificial loss of substances, trauma- 
 
CICATRICES 337 
 
 tism, wounds, accidental or surgical incision; a caustic agent, a 
 burn, etc. 
 
 2. Those which result from some ulceration. 
 
 3. Those which are derived from an interstitial pathological 
 process without apparent loss of substance, whose repair has given 
 rise to sclerosis with a marked change in the structure of the skin. 
 Between cicatrices of this kind and what I shall describe as cicatricial 
 atrophies, it is not really possible to trace a distinct border-line. 
 
 Although no cicatrix is strictly pathognomonic in itself, its prob- 
 able origin can often be surmised; and scars being indelible consti- 
 tute stigmata of special value. 
 
 In estimating the symptomatic significance of cicatrices, it is 
 necessary to keep in mind especially their extent, their number 
 (variola, acne), their configuration (syphilis, tuberculosis), their 
 seat (bubos, chancroids, chancres, lupus, etc.), their depth (ulcers, 
 etc.), and even their color (favus, syphilis, etc.). It must be remem- 
 bered, however, that their features may be modified by various 
 accessory factors, superadded infections, faulty dressings and an 
 unfavorable general, regional or local territory. 
 
 Among the pustular and ulcerative affections which leave 
 cicatrices, I shall mention variola, ecthyma, pustular acne, acne 
 necrotica, furuncle, carbuncle, ulcerative zona, soft chancre; the mul- 
 tiplicity of cicatrices of this type, their small extent and their locali- 
 zation are more or less plainly characteristic. 
 
 All tubercles, syphilitic, tuberculous or leprous, are almost neces- 
 sarily followed by cicatrices; and this fact is implied in the definition 
 of these lesions as non-resolutive. 
 
 For simplicity's sake, I shall proceed to sum up the features of the 
 cicatrices caused by these three great infections, independently of 
 the original lesion. 
 
 In syphilis, the chancre leaves a cicatrix only when it has ulcer- 
 ated; actually, in nearly one-half of the cases. 
 
 Ulcerative secondary syphilides may spatter the integument with 
 more or less deep, flat or honeycombed cicatrices, often with a 
 pigmented border. 
 
 The cicatrices of ulcerative or gummous tertiary syphilides are 
 said to be characteristic on account of their white and smooth 
 appearance with a zone of peripheral pigmentation. In reality, it 
 is their configuration and arrangement which are of special diag- 
 nostic value; they generally have sharp and regular contours, 
 orbicular or semicircular, or are made up of disks arranged in arcades, 
 or of reniform polycyclic patches. The cicatrices of tubercular 
 syphilides are often of irregular surface, honeycombed, purplish 
 or brownish, checkered with white stars. 
 
 The presence of round and very superficial cicatrices on the 
 22 
 
338 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 buttocks may be cited in favor of n diagnosis of congenital syphilis; 
 but their value would lie very small in the absence of other stigmata. 
 Radiating cicatrices of the lips are on the contrary very charac- 
 teristic in themselves. 
 
 The cicatrices of ulcerated tuberculosis, bony, articular or glan- 
 dular, as well as those <»f tuberculous gummas and ulcers, are often 
 distinguished by their irregular, sinuous and eroded contours, and 
 their uneven surface, which presents retracted strands, promon- 
 tories and bridges. The latter — consisting of minute strands ad- 
 herent only by their extremities (under which horny scales, colored 
 black by dust, accumulate) and which can he raised by slipping 
 a pin underneath possess, I believe a real diagnostic value for 
 tuberculosis; but they are not absolutely pathognomonic, for I have 
 -ecu "bridged" cicatrices as a sequel of sporotrichotic lesions, of 
 carbuncle in a diabetic patient, etc. 
 
 Lupus leaves very variable cicatrices, according to its varieties; 
 flat, white and smooth in its erythematous resolving form; thicker, 
 often rose-red, sometimes vicious and keloidal, in the deep forms. 
 They may cause serious deformities of the orifices of the face, for 
 example ectropion, stricture or atresia of the nares and the mouth; 
 adhesions of the fingers or toes (Fiji - . 170), contractions of the joints, 
 etc. They are frequently the seat of renewed growth of lupus 
 nodules. 
 
 Leprosy furnishes very variable cicatrices, superficial or deep, 
 supple or very sclerotic, prominent or depressed, following upon 
 bullae, leprides and especially upon tubercles and infiltrations; 
 they are often described as morphoea leprosa; they are white, or 
 sometimes deeply pigmented and are characterized by their anes- 
 thesia. Aside from these morpheas, mention must be made of the 
 deep cicatrices left by the ulcers of leprosy and the diffuse dermato- 
 <clerosis of the extremities in the mutilating form 
 
 The vegetative dermatoses — such as, Oriental boil, yaws, pem- 
 phigus vegetans, iodide and bromide eruptions, etc. — also leave 
 cicatrices, often irregular, with pigmented borders. Needless to 
 say, this is likewise true for ulcers of all kinds, phagedenas, ^an- 
 grenes; the scars which follow depend in the extent, configuration 
 and depth of the original lesions. 
 
 The same remark applies to tumors, which may give rise to 
 cicatrice-, benign tumors like certain nevi mollusci or absorptive 
 angiomas and malignant epitheliomatous tumors. In this way, 
 secondary carcinomas of the skin, ulcerated or not, of the type 
 formerly named scirrhus, become the seat of a fibrous thickening 
 which appears exactly like a lardaceous scleroderma. Finally, in 
 cutaneous epithelioma of the variety known as flat cicatricial epi- 
 thelioma, the center of the patch is often seen to become sclerotic, 
 
CICATRICES 339 
 
 the epithelial newformation remaining demonstrable only at the 
 borders in the form of a narrow beaded margin. 
 
 It is useful to know that vice versa cicatrices may become the 
 starting-point of epithelioma which is generally of the lobulated 
 type. 
 
 The diagnosis of the origin of cicatrices is often greatly helped 
 by the history, by serodiagnosis and by the general examination of 
 the patient. 
 
 Cicatricial Atrophies. — Alongside of these often irregular and im- 
 portant cicatrices which have just been discussed, must be placed 
 more discrete, usually macular lesions, of atrophic appearance in 
 the clinical sense of the word. The name of cicatricial atrophies is 
 reserved for these lesions. 
 
 Cicatricial atrophy, generally in the form of white, flat, smooth, 
 more or less indurated patches, is the inevitable result of lupus ery- 
 thematodes discoides, the different forms of depilating folliculitides, 
 and Brocq's pseudo-alopecia; of the resolutive tuberculous lupus; 
 tubercular syphilides and the majority of non-ulcerating lepromas. 
 
 It characterizes a variety of lichen, known as lichen planus 
 atrophicus. 
 
 Several bullous affections, notably pemphigus congenitalis, leprous 
 pemphigus, rarely Duhring's disease, leave spots or patches of 
 thinned skin, often pigmented or purplish, somewhat indistinctly 
 outlined. 
 
 Small atrophic and leukodermic spots, associated with pigmenta- 
 tions, are noted in various dystrophies, such as xeroderma pigmen- 
 tosum, senile degeneration, etc. 
 
 Keratosis pilaris, on healing, leaves behind it a crop of punctiform 
 cicatrices, the site of which is typical. 
 
 Favus very often produces large, smooth, bald and cicatricial 
 surfaces, usually of a pinkish color, but sometimes decidedly white. 
 
 Mention must also be made of radiodermatitis, which even in the 
 absence of ulceration, may be followed by white cicatricial atrophies 
 with diffuse borders, mottled by telangiectases and pigmentary 
 spots. 
 
 The fact that certain erythematous dermatoses terminate in 
 cicatricial atrophy, led Unna to establish his group of ulerythema 
 (from ov\t] = cicatrix), comprising a centrifugal type, lupus erythe- 
 matodes, and ophryogenic and sycosiform types. 
 
 This atrophy-producing tendency belongs also to certain erythe- 
 matous tuberculides. Finally, some special cases of erythema, 
 urticaria and purpura, have been known to terminate in cicatricial 
 atrophies, which have been compared with the idiopathic macular 
 atrophies. 
 
 The diagnosis of the origin and nature of these cicatricial atrophies 
 
340 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 generally rests upon their form, their dimensions, their number, their 
 topographical seat; sometimes, it has been possible to follow their 
 development, or the original lesions can be discovered, either at the 
 circumference of the spots or elsewhere. 
 
 Summarizing, the clinician when confronted with an atrophic or 
 sclerotic spot must think in the first place of a cicatrix and inquire 
 as to its origin; next, if there is no genuine cicatrix, he must think 
 of the cicatricial atrophies; the processes which may terminate 
 in a lesion of this nature have just been shown to be extremely 
 numerous and different; all possible theories should be reviewed; 
 third, when all the preceding conditions can be excluded, it is justi- 
 fiable to assume an idiopathic macular atrophy. 
 
 Pathological Anatomy. — The pathological anatomy of cicatrices 
 varies according to the depth and character of the lesions which 
 have caused them. The cutis, or at least the papillary body, must 
 have been involved, for otherwise repair would have occurred with- 
 out a scar. 
 
 In a general way, their structure is as follows: the epidermis is 
 more or less thick, often hyperkeratotic or parakeratotic, smooth, 
 or sends out a few irregular proliferations at its deep aspect, it covers 
 a dense fibrous tissue, composed of parallel connective-tissue bundles, 
 deprived of elastic fibers or at least of a regular elastic network. 
 
 The papilla? and the entire papillary body are often missing. 
 In the spaces between the fibrous tissue rows of embryonic or 
 plasma cells and often very numerous mast-cells persist for a long 
 time. The vessels, relatively scanty, but often telangiectatic under 
 the epidermis, follow variable paths, having nothing in common 
 with the normal vascular distribution. Not infrequently, there are 
 collections of pigment in the gaps of the fibrous tissue adjacent to 
 the epidermis, in the area or at the circumference of the cicatrix; 
 more rarely, pigment is noted in the epidermis itself. 
 
 The hairs and pilosebaceous follicles, as w r ell as the sweat-glands, 
 are absent or sometimes transformed into milium cysts. 
 
 Treatment. — Cicatrices may, in the course of time, become flexible 
 and resume a nearly normal color; but they are never entirely 
 obliterated. 
 
 The prophylactic treatment of vicious cicatrices consists in the 
 use of proper dressings, autoplastic operations: the so-called 
 epidermic grafts of Reverdin, or dermo-epidermic grafts of Ollier- 
 Thiersch, or the small deep skin grafts of American writers may be 
 indicated in cases of extensive loss of substance. 
 
 Sometimes, when circumstances are favorable, it may be advan- 
 tageous to excise a disfiguring cicatrix, in order to replace it by a 
 less evident linear scar. Local massage, sometimes scarifications, 
 often the application of mercurial ointments or radiotherapy, may 
 
LINEAR AND MACULAR ATROPHIES 341 
 
 improve an unsightly cicatrix. Injections of thiosinamin or fibrol- 
 ysin are not devoid of danger and yield few durable results. As 
 regards keloids, this subject will be discussed further on. 
 
 By means of ionization of a solution of potassium iodide on the 
 negative electrode, it is possible to liberate, make supple and bleach 
 vicious cicatrices, even in longstanding cases (Chiray and Bour- 
 guignon.) 
 
 LINEAR AND MACULAR ATROPHIES. 
 
 Linear atrophies — called- "vergetures" in French, from their 
 resemblance to the livid streaks left on the skin by blows with a 
 strap or rod — are also known as stria? atrophica?, stria? gravidarum, 
 striee distensa?, etc. 
 
 These are cutaneous atrophies of elongated form, prominent, 
 level or depressed, but always soft and indentable — which seem to 
 to be due to overstretching of the skin ; they are indelible, but often 
 become less visible in the course of time. 
 
 Linear atrophies have a length of one to several centimeters, a 
 width of 1 to 10 mm., or more, their form is elongated, spindle- 
 shaped and often undulating. Their color, of a dusky or bluish red 
 when they are recent, frequently passes into a pearly white; some- 
 times, on the contrary, they are brownish. Their borders are dis- 
 tinct; their surface is smooth, or puckered, or designed in large 
 lozenges; on touch they give a sensation of softness, of relative 
 emptiness; as if a very thin skin were resting on a soft and yielding 
 tissue. 
 
 Almost invariably multiple and usually symmetrical, these linear 
 atrophies may develop in many regions, principally on the abdomen, 
 but also on the thighs, the loins, above the knees, on the flanks, the 
 breasts, the buttocks, etc. Their direction corresponds as a rule to 
 what are known as the lines of cleavage of the skin ; their long axis 
 is perpendicular to the direction in which the maximum tension 
 which seems to have caused them has taken place ; they are usually 
 vertical on the abdomen, the trochanteric and deltoid regions; 
 transverse on the flanks, the loins and above the patella; radiating 
 on the breasts. 
 
 Linear atrophies are much more common in women, even outside 
 of pregnancy (36 in 100 cases in adult women, against 6 per cent, 
 in men, according to Schultze); although pregnancy is the most 
 common cause. They are observed in nine-tenths of all pregnant 
 women though some women never acquire them, even after ten to 
 fifteen confinements. Among other frequent causes of linear atrophies 
 must be mentioned obesity and typhoid fever. 
 
 In an endeavor to ascribe a mechanical pathogenesis to these 
 lesions — a gradual or a rapid distention of the skin which pla} T s an 
 
342 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 evident but not exclusive part in their production attention has 
 been called to the effects of growth, anasarca, voluminous tumors, 
 or traumatisms. 
 
 It is certain, however, that another mechanism intervenes aside 
 
 from this distention. As a matter of fact, linear atrophies may be 
 absent in eases of enormous aseites or very large hernias; in all 
 probability, there is no actual distention of the skin in corpulent or 
 in rapidly growing individuals; linear atrophies may occur even as ;i 
 sequel of emaciation, in typhoid fever, tuberculosis, other severe 
 infections and certain nervous diseases.* I have seen linear atrophies 
 and postsyphilitic atrophies coexisting in the patient shown in Fig. 
 Ill, who had lost weight, from ION to 72 kilos. There is accord- 
 ingly reason to suspect, in affected individuals, the existence of a 
 special delicacy of the skin, notably its elastic tissue, either of 
 congenita] or toxi-infectious origin. 
 
 The pathological anatomy of linear atrophies sufficiently explains 
 their clinical features. The epidermis and the papillary body 
 are spread out or folded, the connective-tissue bundles of the 
 cutis are parallel and atrophied. 
 
 The fundamental lesion consists of the disappearance of the 
 elastic tissue network, the retracted and shrivelled stumps of which 
 are seen on either side of the lesion; it is noteworthy that this 
 rupture is not accompanied by a demonstrable degeneration, such 
 as a transformation in elacin of Unna, etc. 
 
 Linear atrophies show no tendency to repair. No treatment can 
 guarantee their disappearance, although they may be rendered less 
 apparent by hygiene, hydrotherapy, tonics. It is doubtful if sup- 
 porting appliances, pregnancy belts and so forth, are of any use as 
 preventives, but their employment should nevertheless not be 
 neglected. 
 
 Round or Macular Atrophies. — This name, as well as macules 
 atrophica or postsyphilitic atrophies, designates lesions which are 
 entirely analogous, except in form, with linear atrophies. These 
 spots are depressed, level, or prominent, smooth, shrivelled, or 
 pitted, according to the state of tension or relaxation of the skin, 
 lavender or white according to their age and always very soft and 
 depressible. They are round or oval, punctiform or lenticular and 
 are scattered without order, usually in large numbers on the flanks, 
 the chest, the back, or the shoulders ( Fig. 111). 
 
 The relation of round atrophies to syphilis is undoubted; they 
 belong to the secondary stage, sometimes associated with an erup- 
 tion of papular syphilides or with the pigmented syphilide of the 
 neck. Their development could sometimes be followed as a sequel 
 and at the site of lenticular papules. There are cases, however, in 
 which the preexistenee of lenticular papules, or even of roseolar 
 
1D10PA THIC A TROPHIES 
 
 :;i: 
 
 spots, at the atrophic points cannot be demonstrated and is posi- 
 tively denied by the patient. 
 
 The structure is the same as that of linear atrophies and the 
 treatment is equally futile. 
 
 Fig. 111. — Round syphilitic atrophies of the dorso-lumbar region; their elevation, 
 very apparent in extension of the trunk, entirely disappeared when the trunk was 
 flexed or the skin stretched. The patient showed, in addition, linear atrophies on the 
 abdomen and the hips. 
 
 IDIOPATHIC ATROPHIES. 
 
 The qualification "idiopathic," it is needless to state, merely 
 expresses our ignorance as to the underlying causes. In regard to 
 the pathogenesis of these atrophies, although they may sometimes 
 appear primary, they are generally supposed to be the result of a 
 preliminary or concomitant inflammatory process. Cases can be 
 distinguished in which this process is clinically evident and others 
 in which it is not demonstrable ; but it is probable that even in the 
 latter an inflammation is present in the first stages of the affection 
 and could be revealed by histological examination. On this view 
 are based the terms dermatitis atrophicans, erythema atrophicans, 
 etc., which have been suggested. It can by no means be claimed 
 that the group of idiopathic atrophies presents a unit, the contrary 
 being probably true. However that may be, from the morphological 
 point of view, they may be divided into two groups, according to 
 their being diffuse or circumscribed. 
 
 1 . Diffuse Idiopathic Atrophies. — The first observations were made 
 by Buchwald (1883), Touton and Pospelow. Ten years later, F. J 
 Pick described a type of this affection under the name of erythro- 
 
344 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 melia and Herxheimer in his turn, with Hartmann, resumed its 
 study, under the name of acrodermatitis atrophicans chronica. The 
 affection is progressive and develops in interrupted attacks; but in 
 the cases of Kaposi and of Colombini its course was rapid. Its 
 seal of predilection is the limbs, but it may reach also, or inde- 
 pendently, various regions of the trunk, the hips and even the 
 head. The most distinctly marked clinical type is described in the 
 following: 
 
 Erythromelia of Pick, or acrodermatitis chronica atrophicans of 
 Herxheimer.— In this form the dermatosis attacks first the extremi- 
 ties, more particularly the dorsal aspect of the hands and feet and the 
 extensor surfaces of the elbows and knees. It sometimes seems to 
 progress from the periphery toward the center, but usually settles 
 or markedly predominates in the above enumerated regions. The 
 thighs and arms are rarely involved, the shoulders and hips only 
 exceptionally. 
 
 The lesion consists of an atrophy which may seem primary; in 
 other cases, it is preceded by a red edematous infiltration of firm 
 consistence; from the hands and feet, this sclero-edematous infil- 
 tration, which deforms the fingers and toes and impedes their move- 
 ments, may invade the forearms and legs, often in the form of a 
 pre-ulnar and pre-tibial band with redness in the vicinity. 
 
 The atrophy, primary or following this inflammatory stage, is 
 red or rose-colored, slowly extensive and permanent. The thinned- 
 out skin, through which can be plainly seen the venous network and 
 the tendons, is nearly alopecic, slightly squamous and puckers like 
 tissue-paper; on touch, it gives an impression of softness, like that 
 of moist chamois-skin. 
 
 Histology shows, aside from a diminution of the elastic plexus, an 
 edematous and cellular infiltration containing numerous plasmocytes. 
 
 Erythromelia more frequently attacks men of mature age than 
 women. It lasts for years. Its ultimate state is not known; perhaps 
 a few cases terminate in recovery. 
 
 When it is limited to the hands, it might be confused with pella- 
 grous erythema; or in its very extensive diffuse form, with senile 
 atrophy. The presence of an edematous inflammatory infiltration 
 at certain points suffices for the avoidance of these errors. Redness 
 and atrophy serve to differentiate erythromelia from scleroderma 
 at the onset, where the fingers are likewise stiff and infiltrated; but 
 there are eases in which the two processes are combined. 
 
 In the poikiloderma vascularis atrophicans of Jacobi (190!)), or 
 reticular atrophy of Zinsser, the plexiform atrophoderma is com- 
 bined with telangiectasis and pigmentation. 
 
 2. Macular Idiopathic Atrophies. — This second group of cases was 
 established about the same time and parallel with the first, although 
 
IDIOPATHIC ATROPHIES 345 
 
 with less certainty. A few old cases of cyanotic macules (Besnier 
 and Founder) and of erythematous atrophy in patches with periph- 
 eral extension, etc., were known; but this clinical type had no 
 scientific standing until the publication (1891) of Jadassohn's case 
 of anetoderma erythematosum, or atrophia maculosa cutis. 
 
 Galewski, Nielsen, Heuss and others have contributed case- 
 reports; the observation of Thibierge (erythematous atropho- 
 derma) approaches it in certain respects, while also offering points 
 of contact with lupus erythematodes. But the cases of Pellizari 
 (urticarial erythema), Balzer (erythema polymorphe atrophicans), 
 Hallopeau (chronic urticaria with cicatrices), Pospelow (purpura 
 atrophicans), Nikolsky, etc., must according to Heuss be trans- 
 ferred from the group of idiopathic macular atrophies to that of 
 cicatricial atrophies. 
 
 It has been asserted that macular atrophy represents merely a 
 special case, a circumscribed form, of idiopathic atrophy. Certain 
 observations, due to Herxheimer, Thimm and others, seem to 
 establish a transition between the two classes. The objective 
 differences are, however, as a rule, very marked, as appears from 
 the following description. 
 
 Macular Atrophy or Anetoderma Erythematosum of Jadassohn. — 
 There is a scattered, more or less profuse eruption of atrophic spots, 
 sometimes predominating on the extensive surface of the limbs, on 
 the flanks and on the back. Most commonly, they are nummular 
 and rounded, sometimes irregular or even in strise; their color varies 
 from purplish red to pearly white; their contours are distinctly 
 marked by the difference in color and by the depression of the 
 skin at their site; on the least movement, the epidermis on their 
 surface becomes folded. The integument as a whole has a very 
 peculiar doughy and soft consistence; on touch, the spots convey 
 the impression of holes dug in the skin; their flabbiness contrasts 
 with the firm consistence of the atropho-sclerotic spots described in 
 the next section. 
 
 Jadassohn believes he has shown that at the onset the lesion 
 is a dermic papule analogous to a syphilitic papule; others have 
 seen spots appearing atrophic from the start. They progress slowly 
 for several weeks or several months ; sometimes a rose-colored circle 
 marks the zone of invasion; it is said that some spots may completely 
 disappear. 
 
 Nearly all the reported cases were observed in young females who 
 often were tainted with tuberculosis. 
 
 The differential diagnosis must be made from nevi atrophici, 
 from cicatrices and from cicatricial atrophies. I have observed spots 
 of identical appearance in Recklinghausen's disease, the true char- 
 acter of which could onlv be established bv histological examination. 
 
346 CI TANEOVS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 SCLEROTIC ATROPHIES IN SPOTS. 
 
 In juxtaposition to the soft macular atrophy, or anetoderma, a 
 
 place must be assigned to a clinical picture to which attention has 
 been drawn by many recent publications. It consists of both atrophic 
 
 and sclerotic spots, of a glistening, pearly or porcelain white, level 
 or slightly depressed, firm on touch, which appear in variable number 
 in certain regions. Their dimensions vary in the same case from a 
 pin-head to a silver quarter, hut they may become confluent in 
 larger >pots. 
 
 It is more than probable that this syndrome docs not constitute 
 a single affection. American and English writers designate it under 
 the name of White spot disease, first employed in 1903 by Johnston 
 and Sherwell. It may he brought about either by lichen planus 
 scleroticus or by morphea guttata. In a given case, an effort must 
 he made to differentiate between these two affections, on the basis 
 of what will follow. This is often impossible and the question then 
 arises if there is not another pathological entity of nearly identical 
 appearance. 
 
 Lichen planus scleroticus vel atrophicus (Fig. 35) is met with in 
 both sexes and may be situated in any region of the body, but 
 especially at the nape of the neck and on the wrists; the small white 
 spots, finely criss-crossed, not frequently studded with horny plugs, 
 may have a slightly raised border; they begin as polygonal papules 
 of tawny hue and accordingly represent cicatricial atrophies. When 
 there is a coexisting ordinary lichen planus on the integument or 
 on the buccal mucosa, this of course settles the diagnosis. The 
 histology of the lesions shows a small patch of subepidermic sclerotic 
 atrophy, under which may be found, in recent lesions, a remnant of 
 the circumscribed cellular infiltration belonging to lichen planus. 
 The lichen albus of Zumbrusch, be it stated, is nothing other than 
 this sclerotic lichen planus. 
 
 Morphcea guttata, or superficial circumscribed scleroderma, or parch- 
 ment-like scleroderma ( "Kartenblattaehnliche morphoea," of Unna) 
 or white-spot disease, properly so called, is observed rather in young- 
 girls or women of any age, more or less tainted with tuberculosis; 
 its seat of predilection is on the upper chest, the shoulders, the 
 neck, the nape of the neck and the perigenital region. The lesions 
 which arc lenticular or nummular with a tendency to depression, 
 are of a pearly or porcelain-white color and are bordered by a 
 narrow pink or purplish /one; they may bear a few thinly scattered 
 horny plugs; the sclero-atrophic spots originate under this form and 
 may in all probability disappear; their number is very variable. 
 
 The condition represents a slight hyperkeratosis, with a patch 
 of compact thickening in the cutis of modified staining capacity, 
 
SCLERODERMA 347 
 
 poor in cellular elements; the preliminary pathological process is 
 unknown. 
 
 Several cases of white spots coexisting with scleroderma in patches 
 or in bands have been published; however, the relationship between 
 these two affections is not certain for all the cases, some authors 
 have thought of a relation with lupus erythematodes. 
 
 Treatment by means of radiotherapy, electrolysis and thyroid 
 extracts, seemed to be beneficial in several cases. 
 
 SCLERODERMA. 
 
 In the very extensive realm of the dermatoscleroses, the sclero- 
 dermata form a limited group which comprises apparently idiopathic 
 affections, meaning that their nature is entirely unknown. They are 
 divided into four groups : 
 
 Sclerema Neonatorum. — A child, born apparently quite healthy, 
 may present at the end of a few hours, or after two to ten days, 
 sometimes still later, a progressive induration of the integument, 
 constituting sclerema. 
 
 The affection, which is very rare, begins at the posterior portion 
 of the lower limbs, reaching the loins, the back and the entire body ; 
 it may also begin in the face. 
 
 The skin, of a yellowish, livid, or lilac white, is not depressible 
 with the finger, as in edema, but firm and cannot be folded. Move- 
 ments are impeded, the infant is unable to take the breast, emacia- 
 tion is rapid, respiration is interfered with, the pulse is slowed and 
 death is apt to supervene in three or four days, almost invariably 
 with hypothermia or in convulsions. 
 
 This disease, which presents the behavior of an infectious process 
 of indefinite character, differs altogether from congenital generalized 
 cutaneous atrophy. It has likewise nothing in common with fetal 
 ichthyosis, in which the integument is red, tense and covered with a 
 carapace of scales. 
 
 For the treatment of sclerema, the children must be kept warm in 
 the incubator and fed with a stomach-tube, if necessary. Cures 
 have been observed to follow mercurial inunctions. 
 
 Generalized Scleroderma. — This disease, also named edematous 
 scleroderma (A. Hardy), or sclerema of adults, or sclerema (Besnier), 
 manifests itself in two forms: 
 
 In the acute form, the onset is sudden and the course is rapid. 
 The patient complains of stiffness, impairment of movements of the 
 trunk and limbs; breathing becomes difficult, the integument be- 
 comes thickened and diffusely indurated. This form is very rare 
 and often fatal in a few weeks, or at most a few months. 
 
 The slow form,, likewise uncommon, is preceded by prodromata: 
 
348 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 disturbances of the general health, emaciation, febrile attacks, 
 neuralgias and arthralgias, stiffening of the limits, heat and itching 
 in various portions of the skin, sometimes with erythema, or local 
 syncope, or edema, or secretory disturbances, hyperidrosis and so 
 
 forth. 
 
 Next follows a sclero-edematoiis period, during which the integu- 
 ment of the entire body and the limits or of extensive areas becomes 
 thickened, infiltrated with a sort of lardaceous, non-depressible 
 edema, with adhesion to the subjacent tissues; so that it is indurated, 
 tense and cannot be folded. The color is a yellowish white, inter- 
 spersed with gray or brown or lilac spots. The face becomes like 
 marble, its folds disappear, movements of the eyelids, forehead and 
 lips become impossible; speech and the ingestion of food are ham- 
 pered. The induration of the neck and the chest interfere with 
 respiration, sometimes with swallowing. The limbs are stiff or 
 actually immobilized, more seriously affected in their first segments 
 than at the extremities. The boundaries of the affected regions are 
 always diffuse. 
 
 The sclero-atrophic period gradually follows upon the preceding, 
 usually after a few months. The skin becomes fibrous, retracted, and 
 adherent to the muscles and the bones; the subcutaneous panni- 
 culus disappears; the muscles are themselves sclerotic and move- 
 ments are furthermore impeded by fibrous bands. The mucous 
 membranes may be involved. The patients are enormously incon- 
 venienced by the cuirass in which they are enclosed and they com- 
 plain of persistent cold; sensibility is preserved. 
 
 Sclerema supervenes as the sequel of a fall into cold water, a severe 
 traumatism, or an infectious disease. Its course is in attacks, with 
 remissions; death results most commonly from pulmonary, digestive 
 or renal complications, or through cachexia. 
 
 Progressive Scleroderma, Sclerodactylia.— The onset here is on 
 the upper extremities, rarely in the face. This form is systematized, 
 symmetrical and progressive. 
 
 The first symptoms consist of nervous and vascular disturbances, 
 numbness, sensations of cold, spasms, shooting pains, local asphyxia 
 or local syncope; they occur in attacks, as in Raynaud's disease, 
 or may be constant; occasionally hyperidrosis or pemphigoid bullae 
 have been noted. These phenomena may be continued during 
 months and years. Asphyxia of the nose and ears, and paresthesias 
 of the face, have also been observed. 
 
 In the fully developed stage, which supervenes at the end of several 
 months or years, the fingers become pointed, their skin is thinned 
 and adherent to the bones; they appear hard and dry, can no longer 
 be flexed or extended and are of a grayish or slightly livid color. 
 The process begins at the last phalanges, reaching the root of the 
 
SCLERODERMA 
 
 349 
 
 fingers, the hands, the forearms, etc. The fingers transformed into 
 rigid fusiform sticks may become the seat of sluggish ulcers or of 
 gangrenes, or bony disintegration; terminating in mutilations like 
 those of leprosy. The nails are raised, thinned, or onychogry photic. 
 The hypoderm, the muscles and tendons participate in the sclerotic 
 induration, thereby leading to a real mummification. 
 
 Entirely analogous, although usually less pronounced alterations 
 occur in the lower extremities (Fig. 112), the toes become turned out- 
 
 Fig. 112. — Progressive scleroderma. 
 
 ward; ulcerations and a certain degree of plantar keratoderma 
 are not uncommon. 
 
 In the face, the appearance is characteristic; even more so than 
 in generalized scleroderma. 
 
 The wrinkles and folds are obliterated, the features are fixed and 
 immovable; the ears are rigid, the nose is pointed, the lips are thin 
 and tense, the eyelids cannot be completely closed, mastication and 
 deglutition are impeded; the tongue may become atrophied. I 
 have seen aphonia resulting from an involvement of the larynx. The 
 neck, the chest and the entire thorax are finally affected and, to a 
 less degree, the thighs and the abdomen. 
 
 Abnormal 'pigmentations, often occurring early, form an integral 
 
351 » ' UTANEOl s A TROPHIES, Si 'LEROSES AND DYSTROPHIES 
 
 part of the picture; they are sometimes diffuse and limited to the 
 sclerotic portions, often much more extensive, macular, mottled or 
 plexiform. 
 
 In a few rare east's, the production of subcutaneous calcareous 
 concretions has been noted, appearing primarily and predomi- 
 nantly on the fingers (Thibierge and Weissenbach, 1 * > 1 1 ). [A unique 
 case of cutaneous ossification in scleroderma has been recorded by 
 Pollitzer, 1917.] 
 
 The course is slow, interrupted by remissions; death is the result 
 of complications or of cachexia; it may occur suddenly. 
 
 Atypical cases have been noted, beginning with sclero-edema and 
 accompanied by erythema. The association of sclero-edema in patches 
 with sclerodactylia has also been observed. The diagnosis of the 
 clinical form may present some difficulties on account of these trans- 
 itions which, moreover, justify the classification of all sclerodermas 
 in a single group. 
 
 The differential diagnosis from Raynaud's disease may be impos- 
 sible at the onset; although sclerosis of the skin is not the initial 
 and dominating feature of this condition, there occur true mixed or 
 intermediate cases. 
 
 Lepra nervorum is characterized by anesthesia, muscular atrophy 
 and thickening of the nerves. 
 
 In syringomyelia, there exists a dissociation of sensibility, but no 
 true sclerosis. A confusion with progressive arthritis deformans 
 could be due only to faulty observation; the stiffness and the deform- 
 ity of the fingers in this case are not referable to the condition of the 
 >kin, which is thinned but remains normal. Association is, however, 
 possible and has been demonstrated. 
 
 The frequent pigmentations of scleroderma should be kept in 
 mind in order to avoid confusion with other melanodermas. 
 
 Partial Sclerodermas. — The sclerotic lesions may be circumscribed, 
 either in patches with well defined contours, or in bands and in rings. 
 
 Scleroderma in Patches. The patches of scleroderma, also known 
 ;i- morphea, differ from cicatrices by their spontaneous and primary 
 appearance as well as by their course. They are distinguished 
 from the macular atrophies by their sclerotic character. 
 
 Morphea begins as a more or less thickened and indurated, 
 lilac or purplish >pot. which slowly increases in size; at the end of a 
 \\'\v weeks or months its center becomes whitened and indurated, 
 often through confluence of originally isolated sclerotic points. 
 According as the patch is level, infiltrated, or mammillated, a dis- 
 tinction is made between morpheas alha plana, lardacea and tuberosa; 
 hut the appearance may change in the course of development. I 
 have described above under Morphaa guttata, white-spot disease 
 
 the form in which the induration resembles parchment and i> 
 merely superficial. 
 
SCLERODERMA 351 
 
 The patches of morphea have a variable extent, from 1 to 20 
 cm., or larger; an oval or irregular shape, with convex or sinuous 
 borders; of a glistening, pearly, bluish, or wax-white color. They 
 are sometimes spotted with pigment, or mottled with telangiectases, 
 or they may desquamate in large shreds. Their most characteristic 
 feature is that they are usually bordered by a zone of mauve, pur- 
 plish or tawny color, several millimeters in width, constituting the 
 lilac ring of authors. The consistence of the patches is hard, even 
 woody; they cannot be folded; sometimes they are more or less 
 closely adherent to the subjacent layers, the bones and the muscles. 
 
 On these patches the hairs have fallen out, the secretions are 
 absent, sensibility is lessened in proportion to the degree of the 
 sclerosis; at the onset, tickling and itching sensations have been 
 noted. 
 
 Morphea spots may be single or multiple, sometimes symmet- 
 rical and occupy any region of the body. They are not uncommon 
 in the face. On the hairy scalp, confusion must be guarded against 
 with the cicatrices from lupus erythematodes or other causes. On 
 the chest, they must not be confused with scirrhus cancer. They 
 are also seen on the abdomen, often on the limbs and even on the 
 buccal mucosa; in the last named location, they assume the shape 
 of hard white spots, which are retracted, in contradistinction to 
 leukoplakia. 
 
 The patches of morphea after remaining stationary sometimes 
 for a very long time, may begin to spread; or they may give rise 
 to obstinate ulcers at points exposed to injury. Most commonly, 
 they finally undergo retrogressive changes, the lilac ring disappears, 
 the extent of the patch narrows, its center shrivels, becomes supple 
 and covered with superficial telangiectasis. A localized atrophy 
 is left behind, known as morphea atrophica. It is said that total 
 disappearance may occur. 
 
 Scleroderma in Bands. — Instead of patches, the sclerosis may 
 form bands, 2 to 5 cm. wide, with broadening and narrowing here 
 and there. Their length is variable; they may extend, for instance, 
 from the shoulder to the hand, or from the pelvis to the heel. The 
 sclerotic band is prominent or level, or depressed as a groove, and 
 may impede movements. The lilac ring is rarely complete. 
 
 A relatively not uncommon clinical type (numerous cases of which 
 were presented at the London International Congress, 1896) is 
 is that of frontal scleroderma; a white or brownish depressed 
 sclerotic band, starting from around the superior orbital foramen, 
 passes across the forehead, like a sabre-stroke, terminating more or 
 less close to the fontanelle. 
 
 A possible relation of the course of sclerodermatic bands with the 
 nervous, radicular, etc., territories has been pointed out; but these 
 relations are irregular and very inconstant (see linear nevi, p. 206). 
 
352 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 Annular Sclerodermas.- In exceptional cases, a band of sclero- 
 derma has been seen to hollow an annular or semiannnlar groove 
 around a limb or around a finger. The stricture may produce 
 edema and elephantiasis below it. 
 
 Analogous appearances may he produced by two other affections, 
 positively distinct from annular scleroderma. 
 
 One of these is ainhum, of Da Silva Lima — or spontaneous 
 amputation of the toes — which is endemic in several colored races 
 and begins in adult life, almost invariably at the little toe, which it 
 strangles and finally separates. 
 
 The other, known as congenital amputations, is observed in all 
 races, affects the limbs at any level and is attributed to an intra- 
 uterine constriction by amniotic bands. Separation is incipient at 
 birth and may become complete in a few weeks or years. 
 
 Pathological Anatomy. -The lesions of scleroderma, no matter of 
 what clinical form, consist of a thickening with partial disappear- 
 ance or sometimes a degeneration of the connective-tissue bundles; 
 the elastic fiber plexus is preserved and appears increased as the 
 result of close approximation of the fibers. It is not known if this 
 fundamental lesion is the outcome of an always identical process. 
 
 In recent cases of generalized scleroderma and scleroderma in 
 patches, I have demonstrated a subacute, predominantly peri- 
 vascular inflammation and a newformation of connective tissue. 
 The smooth muscles may be hypertrophied. The vessels were almost 
 invariably found to be affected by endoperiarteritis and phlebo- 
 sclerosis; the peripheral nerves are slightly involved, or their sheath 
 i- thickened. 
 
 The papillary body is flattened and obliterated, the epidermis is 
 often atrophied; the horny layer is increased. The follicles and 
 glands disappear. Sclerosis of the hypoderm and of the muscles has 
 been described, with inflammation of the periosteum and rarefac- 
 tion of the bony substance; incongruous lesions, of doubtful signifi- 
 cance, are found in the nerve centers. 
 
 In a case of generalized scleroderma, of hyperacute onset, observed 
 by Thibierge, I found the following changes: in the sclerematous 
 Stage, ;i thickened epidermis, a tendency to obliteration of the 
 papilla?, a condensation of the papillary body where the elastic 
 plexus was irregular and ravelled; in the stage of sclerotic atrophy, 
 a thinned epidermis apparently glued to the corium, disappearance 
 of the papillae, a narrow and sclerotic papillary body supplied with 
 several layers of elastic fibers parallel with the surface; no sign of a 
 cellular infiltration. 
 
 Etiology and Pathogenesis. Scleroderma is more common in the 
 female sex. The diffuse forms are met with especially between 
 twenty and forty years, the partial forms, at uuy age. 
 
REGIONAL ATROPHIES AND DERMATOSCLEROSES 353 
 
 Sudden exposure to cold, violent emotions, overexertion, men- 
 strual disturbances, are frequently held responsible; the probable 
 action of traumatism has been pointed out for the localized and even 
 for the generalized forms. It seems that several infections may 
 play a part, especially acute rheumatism, typhoid fever, etc., 
 perhaps tuberculosis or congenital syphilis. In a general way, very 
 little is known concerning the etiology of the sclerodermas. 
 
 The pathogenesis is equally uncertain. Vascular lesions are prac- 
 tically sure to occur. The effect of a trophic or angioneurotic 
 nervous disturbance has been suspected, on account of the arrange- 
 ment of certain sclerodermas in bands and the common nervous 
 antecedents of these patients. Cases where sclerodermas super- 
 vened in the course or as a sequel of exophthalmic goitre have given 
 rise to the thyroid and polyglandular theory. Various infections or 
 toxic influences possibly act upon the nervous system and the 
 vascular apparatus, through the intermediation of functional dis- 
 turbances of the internally secreting glands. [The probabilities 
 seem to me to indicate that endocrinal disorders are the most 
 likely etiological factor.] 
 
 Treatment. — Nearly every kind of internal medication has been 
 tried in the diffuse sclerodermas; there are no specifics and each case 
 will have to be treated according to its own indications. 
 
 Salicylates have seemed to be useful to me; others have advo- 
 cated the iodides, arsenic and fibrolysin. Successful results have 
 been obtained with thyroid treatment, cautiously and persistently 
 administered, but are unfortunately not constant. 
 
 Aside from good hygiene, advantageous use may be made of 
 hydrotherapy, the continuous current, electric baths, massage, treat- 
 ment with sulphurous or chlorinated waters, various hot springs and 
 mud-baths. 
 
 In the partial sclerodermas, negative-pole electrolysis may be 
 recommended; the punctures must be applied at considerable 
 intervals and only weak currents be used; ionization has likewise 
 yielded very encouraging results. Massage, salicylic acid or salol 
 ointments are sometimes beneficial. Mercurial plasters have a 
 classical reputation. Several of these treatments may, moreover, 
 be combined. 
 
 REGIONAL ATROPHIES AND DERMATOSCLEROSES. 
 
 In addition to the macular sclerodermas and atrophies, there 
 exist a certain number of clinical types in which the lesions, while 
 morphologically analogous, are distinctly regional. 
 
 Whether they be related or not to the affections described above, 
 23 
 
354 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 the identity of the derniatological lesion leads me to consider them 
 in this connection. 
 
 Facial Hemiatrophy. — This affection — also known as tropho- 
 neurosis facialis or aplasia laminaris — consists of a very marked thin- 
 ning of the skin of one-half of the face, without sclerosis or adhesion. 
 The atrophy extends to the corresponding half of the palate, the 
 velum and sometimes the tongue. The prominences of the bony 
 framework are likewise reduced. The affected side seems to be 
 changed as if by old age and situated on a plane behind its normal. 
 The skin is white or pigmented; the sensibility is intact, but 
 anidrosis and alopecia are present. 
 
 This Aery rare affection begins in youth in the form of patches 
 which gradually spread. Some authors compare it with sclero- 
 derma. Cases of coincidence of this disease with a scleroderma in 
 extensive patches have been reported. 
 
 Kraurosis Vulvae. — The term "kraurosis" (Breisky), the meaning 
 of which was rather vague, has been more accurately defined 
 especially by the work of Jayle, and must be reserved for a pro- 
 gressive sclerotic atrophy of the cutaneo-mucous tissues of the vulva, 
 gradually leading to stenosis of the vaginal orifice, disappearance 
 of the labia minora, the prepuce and frenum of the clitoris and the 
 obliteration of the labia majora. [I have seen the process extent 
 to the anal orifice.] The mucosa of the affected regions is always 
 smooth, glistening, and dry; its color is white, or red, or mottled. 
 Complication with leukoplakia is common and, in this case, cancer 
 is not rare. 
 
 The exclusive or principal pathogenic condition of kraurosis 
 seems to be the suppression of the ovarian functions through senile 
 involution, sclerotic atrophy, or castration; syphilis seems to play 
 a part in some cases. 
 
 Kraurosis must not be confused with simple vulvar leukoplakia 
 nor with the white coloration of the vulva through lichenization, 
 which occurs in prolonged cases of vulvar pruritus. Aside from treat- 
 ment with warm irrigations and the high frequency current, exten- 
 sive excisions must not be delayed in cases of threatened cancer. 
 
 Dermatoscleroses of the Legs. — In many adults and in old people 
 the skin of the legs is the seat of very polymorphous but equivalent 
 pathological changes which may terminate either in sclerotic atrophy 
 or in elephantiastic pachyderma. 
 
 In the etiology, the patient's sex is of small importance; but 
 predisposing conditions are represented by an age between thirty 
 and forty-five years, laborious occupations requiring prolonged 
 standing, repeated pregnancies, phlebitis, traumatisms, etc. Re- 
 cently, the influence of syphilis and tuberculosis has been inves- 
 tigated. The essential factors seem to be arteriosclerosis and 
 
CUTANEOUS DYSTROPHIES 355 
 
 especially varicosities. Both legs are usually involved, although in 
 different degrees. 
 
 Varicosities, especially the deep and slightly apparent ones, lead 
 to congestion and lowered nutrition; edema and hematic pigmen- 
 tations follow; the soil is prepared for complications, varicose 
 eczema, phlebitis and ulcers, which further aggravate the nutri- 
 tional disturbance by giving rise to thromboses and opening an 
 avenue to infections, lymphangitis, etc. 
 
 The resulting dermatosclerosis, which is alone to be discussed in 
 this place, may be diffuse or circumscribed. 
 
 In the former case, the diffuse form, the skin is adherent to the 
 tibia and the aponeurosis, of a pasteboard-like or woody hardness, 
 impossible to raise or fold; its color is earthy or checkered with 
 purple or brown, with depressed white spots. Its surface is smooth, 
 shining or scaling and cracked; sometimes it is covered by a thick 
 layer of dry or oily brownish crusts under which may be found 
 pinkish, moist or plainly eczematous surfaces. These changes 
 surround the entire circumference of the leg and extend as far up 
 as the knee; the foot is usually merely edematous and the nails 
 onychogry photic. 
 
 In the circumscribed form, there exist one or several hard, pinkish 
 or pigmented patches, level with the skin or slightly depressed, 
 deeply adherent, often extending into the hypoderm in thick 
 nodular strands. These are sclerotic foci of periphlebitic origin. 
 A variety of reticulated sclerosis, of checkered hue, is also met with, 
 especially in the neighborhood of the ankles. 
 
 This dermatosclerosis is differentiated from progressive sclero- 
 derma by its definite localization; from scleroderma in patches by 
 the absence of a distinct boundary and a lilac ring; from the cica- 
 trices of ulcers, which often exist at the same time, by the absence 
 of a distinct thickened border, which is characteristic of the latter. 
 
 The efficacy of the treatment depends upon the degree and dura- 
 tion of the lesions. Complete rest in bed, with elevation of the 
 legs, cleanliness and the dressings required by the condition of the 
 skin, lead to progressive improvement, which is often considerable 
 and may be further augmented by massage and radiotherapy. 
 The patient must be instructed to wear roller-bandages or elastic 
 stockings. 
 
 CUTANEOUS DYSTROPHIES. 
 
 Xeroderma Pigmentosum. — This dystrophy was first described by 
 Kaposi and also bears the names of melanosis lenticularis progressiva 
 (Pick), atrophoderma pigmentosum (R. Croker), and epithelioma- 
 tosis pigmentosa (E. Besnier). It is familial and of congenital origin, 
 although it does not manifest itself until the first years of childhood , 
 
356 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 The influence of consanguinity of the parents has been shown by 
 statistics (11.8 per cent, of the cases). Sometimes the children of 
 one sex are alone affected 
 
 The lesions of xeroderma pigmentosum, resulting from an ab- 
 normal sensibility to light-rays, are essentially regional and affect 
 the uncovered regions, face, neck, hands, forearms, sometimes the 
 legs and the feet, rarely the trunk. 
 
 At the onset, usually in the spring or summer and after a solar 
 erythema, the skin is seen to become covered with lenticular pig- 
 mentary spots of the appearance and size of freckles or larger. It 
 soon becomes abnormally dry and peels in fine lamelhe, and later is 
 mottled with telangiectases and atrophic white spots. The latter 
 
 113 
 
 erma pigmentosum. (Author's photograph.) 
 
 may follow upon impetiginous lesions or verrucosities, or originate 
 spontaneously. Finally the tissues become atrophied and con- 
 tracted, whence ectropion, atresia of the mouth, thinning of the 
 nose and ears, etc.; sometimes conjunctivitis and photophobia arc 
 noted. 
 
 The mottled appearance resulting from atrophic and red spots, 
 stellate telangiectases and pigmentary spots, is characteristic. 
 
 More or less delayed, often about the age of eight or ten years, 
 various new-formations appear upon this background (Fig. 113); 
 dry verrucous elevations, red and flabby protuberances of sarco- 
 
CUTANEOUS DYSTROPHIES 357 
 
 matous or angiomatous appearance ; finally, epitheliomas of various 
 types, fungoid or ulcerative, which usually result from the malignant 
 transformation of the warty growths. These various tumors may 
 sometimes heal ; but, as a rule, the epitheliomas become mutilating, 
 involve the glands and lead to early death, usually before the age 
 of twelve years. A few individuals, however, have lived to the 
 age of forty. 
 
 The patholagical anatomy affords scanty information as to the 
 nature of the disease. Epidermic hypertrophy and atrophy of the 
 derma are demonstrable; the various neoplasms mentioned have 
 their ordinary structure, the epitheliomas are sometimes tubular, 
 sometimes lobulated. 
 
 The nature of xeroderma consists primarily of a cutaneous mal- 
 formation of the type of nevic diseases, characterized by hyper- 
 sensibility of the skin to light radiations which leads secondarily 
 to a degeneration analogous to the degenerative changes of presenile 
 and senile dystrophy, radiodermatitis and arsenic poisoning. 
 
 The prognosis is very grave, but varies with the severity of the 
 case and the treatment. 
 
 The treatment consists principally in the avoidance of sunlight; 
 the covering of the skin with protective pastes containing quinine 
 salts or aesculin; sometimes, it is useful to cover it with masks of 
 mercurial or red oxide plaster. 
 
 Special care must be taken to destroy one by one, and very 
 promptly, the neoplasms which develop, even the simple verrucosi- 
 ties, making use of the curette, the bistoury, the galvanocautery, 
 caustic agents, or electrolysis; radium has recently been recom- 
 mended. Internal medication is apparently of no use. 
 
 Senile Degeneration. — The degeneration or senile atrophy of the 
 skin, which regularly occurs at an advanced age, begins sooner or 
 later after the age of forty, according to the mode of life, the 
 general health and the heredity of the individual. 
 
 Exposure to inclemencies of the weather plays a certain part, 
 the uncovered portions, like the face, the neck and the back of the 
 hands and wrists, being the earliest and worst affected; bad general 
 and local hygiene, excesses, loss of sleep and diseases of all kinds, 
 also act as predisposing factors. 
 
 Senile degeneration manifests itself as changes in the thickness 
 and color of the skin, dryness and a diminished plasticity, which 
 results in wrinkles. 
 
 Two types may be distinguished and are often associated : 
 
 The most common is simple atrophy, characterized by a parch- 
 ment-like thinning, a yellowish, grayish or reddish color and trans- 
 parency of the skin, rendering visible the veins, muscles, and 
 tendons, etc.; its surface is shining or in a state of ichthyosiform 
 
358 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 
 
 xeroderma. Pigmentary or achromic spots, telangiectasis and some- 
 times purpura senilis arc often present at the same time. Aside 
 from the above mentioned regions, the extensor surfaces of the joints 
 are the most affected. 
 
 The second type is colloid atrophy, in which the skin is not thinned, 
 sometimes on the contrary thickened, but of a straw-yellow or old 
 ivory color, an uneven surface like orange-peel, soft and flabby, 
 distended and folded. This condition is observed especially on the 
 neck and the entire face, except the cartilaginous region of the nose. 
 
 Histology shows as the principal lesion an alteration of the 
 elastic fibers. In the atrophic type, they have only become baso- 
 philic (elacine of Unna) and the connective tissue is rarefied. In 
 the colloid type, they are furthermore swollen and perhaps com- 
 bined with the substance of the connective-tissue bundles (collastine 
 and collacine). In this case there is found under the epidermis a 
 continuous felt-like band, from I to § mm. in width, staining black 
 with acid orceine; this is the diffuse elastoma of Dubreuilh (1913). 
 Several authors have erroneously confused this relatively common- 
 place lesion with pseudoxanthoma elasticum. The epidermis is 
 thinned and hyperpigmented. The papilla? are short; the blood- 
 vessels are dilated and surrounded by cells. The glands are atrophied. 
 
 Both types of senile degeneration predispose to the senile keratoses 
 which may lead to multiple epitheliomatosis. 
 
 The treatment must be prophylactic and consists in correct 
 hygiene. Facial massage, which is wrongfully credited with the 
 virtue of curing wrinkles, may seem useful for a while, but is 
 followed as a rule by an exaggeration of the lesions. 
 
 Presenile Dystrophy. — On the uncovered portions of the skin, 
 in persons exposed to all kinds of weather, sailors, automobilists, 
 aviators, coachmen, farmers, mountaineers, etc., changes entirely 
 analogous to those of xeroderma and even more so to those of senile 
 degeneration may be observed after the age of twenty-five or thirty 
 years. 
 
 Diffuse atrophy, pigmentations, cyanosis, telangiectasis and 
 keratosis are met with; this dystrophy also terminates in multiple 
 epitheliomatosis. 
 
 All authors point out the striking resemblance often presented 
 by the skin affected with chronic radiodermalitis to that of xero- 
 derma and the senile and presenile dystrophies. The analogy extends 
 to the identity of the epitheliomatous complications which arc here 
 equally frequent. 
 
 Pseudoxanthoma Elasticum. — Under this name I designated, in 
 1896, a rare affection, characterized clinically by a yellow hue mixed 
 with lilac, with thickening, softness and relaxation of the skin in 
 certain regions. It appears in youthful individuals and in adults. 
 
CUTANEOUS DYSTROPHIES 359 
 
 The changes are preferably localized in the vicinity of the great 
 articular folds, groins, axillae, bends of the elbow and even on the 
 neck; it has never been observed in the face. Furthermore, around 
 the dystrophic surfaces are seen perifollicular spots of the same 
 appearance, of slightly prominent, soft, yellowish papules. 
 
 However, the analogy to xanthoma is only apparent. Histologic- 
 ally the condition is a degeneration of the elastic network of the deep 
 portions of the corium; its fibers swell, proliferate, split and break 
 up into fragments. I have given to this special lesion the name of 
 elastorrhexis. 
 
 Certain authors, especially impressed by the elastic hyperplasia, 
 have interpreted it as an elastoma or hamartoma, regarding this 
 degeneration as a sort of widespread tumor. 
 
 At any rate, the nature of the lesions of pseudoxanthoma (elastor- 
 rhexis), their seat and distribution, as well as the age at which the 
 affection appears, plainly distinguish it from the ordinary senile 
 colloid degeneration, or diffuse elastoma. It progresses slowly and 
 persists indefinitely. 
 
 Colloid Milium. — Also named miliary colloid degeneration of the 
 cutis; this rare dystrophy first described by E. Wagner, then by E. 
 Besnier, manifests itself as translucid, soft yellowish elevations, 
 disseminated or conglomerated, situated on the face, the neck and 
 the upper limbs. This condition should accordingly be studied 
 rather with the benign tumors of the skin (XXXI). 
 
CHAPTER XVIII. 
 CUTANEOUS HYPERTROPHIES. 
 
 Under the name of cutaneous hypertrophy or pachi/derma, I 
 designate a persistent increase in thickness of the skin as a whole, 
 due to an interstitial fibrous hyperplasia. 
 
 Partial thickenings, affecting the epidermis alone, or the papillary 
 body, have been discussed elsewhere (Chapter XI and XII). 
 
 Fibrous or adipose hypertrophy of the hypoderm alone, without 
 thickening of the derma does not belong to the domain of derma- 
 tology. 
 
 Cutaneous hypertrophy is only very rarely generalized, but may 
 be very extensive; it is usually regional. The boundaries of the 
 change are almost invariably rather indistinct. 
 
 In pachy derma, the skin is thickened to a variable degree and 
 changed in its consistence. As a rule, it is firm, unyielding, or 
 actually woody; it is not at all or very slightly depressible, and the 
 indenting finger leaves no dimple; it is incompletely reducible by 
 compression en masse; it adheres to the subjacent tissues and is not 
 easily raised in a fold. Sometimes, however, its consistence is softer 
 and more elastic. The condition of the surface and the color of the 
 affected regions vary greatly in different cases. 
 
 Cutaneous hypertrophy must be distinguished from three related 
 processes, which may, moreover, be combined with it in variable 
 degrees: 
 
 Inflammatory infiltration is due to deposits of embryonic cells, or 
 cells derived from the blood, in the tissues; it behaves like the acute 
 inflammations or, when subacute, it is as a rule more or less circum- 
 scribed and follows a progressive or a retrogressive course. In both 
 cases, however, it sometimes terminates in hypertrophy. 
 
 Edema, the result of a fluid exudate which infiltrates the tissue, 
 is depressible, plastic, retains the imprint of the finger and is entirely 
 reducible by compression en masse, even in chronic cases. Edemas 
 of mechanical or dyscratic origin, such as those of cardiac or Bright's 
 disease, etc., never lead to pachyderma. Inflammatory edemas, 
 on the contrary, are not infrequently the starting-point of pachy- 
 dermas, with which they are connected by imperceptible transitions, 
 as illustrated by the often used term of clephantiastic edema. 
 
 Tumors are circumscribed, heterotopic or hyperplastic new- 
 growths instead of simple hypertrophies. The question often arises, 
 
ELEPHANTIASIS 361 
 
 however, in which group a given swelling properly belongs; for 
 instance, an elephantiasis limited to an eyelid or a labium majus 
 may be mistaken for a myxoma, or a bunch of lymphatic varicosities 
 may have the appearance of a lymphangioma, etc. 
 
 Hypertrophic Dermatoses. — The typical form of pachyderma, 
 whose clinical features and lesions conform to the definition given 
 above, is called Elephantiasis arabum (in contradistinction to 
 Elephantiasis grcecorum, which is leprosy), or briefly elephantiasis. 
 It will be discussed first in order. 
 
 Another section will comprise a series of affections which I group 
 under the heading of non-elephantiastic hypertrophies. These form 
 a very heterogeneous group. The differential diagnosis of the 
 genuine elephantiasis will be discussed in dealing with them. 
 
 ELEPHANTIASIS. 
 
 Elephantiasis is a regional cutaneous hypertrophy characterized 
 by its course and its pathogenesis. 
 
 According to the etiological factors, the following clinical forms 
 are distinguished: Elephantiasis nostras; secondary elephantiasis; 
 filarial elephantiasis and congenital elephantiasis. 
 
 The symptomatology of elephantiasis in general, irrespective of 
 its origin, is as follows: The elephantiastic process begins with 
 edema, the inflammatory character of which is sometimes clearly 
 evident, sometimes not noticeable. Ultimately, a firm non-plastic 
 tumefaction is established, constituting sclerotic or elephantiastic 
 edema. In the fully developed stage, pachyderma is present, com- 
 bined with a variable degree of hypertrophy of the subjacent 
 tissues and associated with all the attributes mentioned above. 
 This process is apparently brought about through the association 
 of three pathogenic factors: lymphatic congestion, inflammation 
 and venous congestion. 
 
 The course of the disease is intermittent; it is indefinitely pro- 
 gressive and more or less extensive. 
 
 Symptoms. — The affected regions are swollen, tense and hyper- 
 trophied; their normal elevations and depressions are obliterated; 
 sometimes, they are crossed by deep grooves. 
 
 The lower limb, for example, which on account of less favorable 
 circulatory conditions, is the chief seat of election in elephantiasis 
 assumes the appearance of a column or an elephant's leg (Fig. 114). 
 The integument is enormously thickened and adherent to the deep 
 tissues. Its consistence, which is that of a doughy firmness at the 
 thigh, usually becomes harder and more resistant as it approaches 
 the malleoli where it is sometimes woody. 
 
 The surface may be smooth and of normal color, or purplish, or 
 
362 
 
 CUTANEOUS iiYi'Eirnioi'iiiF.s 
 
 brownish; again, it may be covered with laminated scales, or 
 cracked hyperkeratoses; in the majority of the cases, it is covered 
 by more or less conglomerated verrucosities, of unequal size, rounded 
 and of the size of a millet-seed to thai of a cherry-pit; or papilloma- 
 tous, acuminate or obtuse and crowded together. These verrucosi- 
 ties may l>e pinkish or white, slightly reducible and translucid like 
 
 Fig. 114. — Elephantiasis nostras, consecutive to an ulcer of the leg. 
 
 large vesicles; in this case, they are due to lymphangiectases or 
 lymphatic varicosities, which can be pricked with a needle and yield 
 a profuse, prolonged flow of lymph (lymphorrhea) ; in other cases, 
 they are hard, polygonal through mutual pressure and often covered 
 with a hyperkeratotic layer, of dry or oily consistence, of a dirty 
 gray or blackish color. Under the crusts, as well as in the grooves, 
 a macerated and fetid epidermis is exposed and sometimes ulcers 
 
ELEPHANTIASIS 
 
 363 
 
 are present having an irregular outline and floor with a sanious 
 discharge. 
 
 On the legs, elephantiasis is unilateral or bilateral. When it is 
 caused by a local lesion, such as an ulcer of the leg, the pachyderma 
 develops below this lesion, consequently on the foot. When the 
 causative lesions are situated higher up, the elephantiasis is on the 
 contrary often limited by the malleoli, forming an enormous cushion 
 which is separated from the foot by one or several deep grooves. 
 The foot may retain its normal volume, but is usually swollen and 
 verrucous in its dorsal region, chiefly near the toes and above the 
 heel. 
 
 Fig. 115. — Elephantiasis of the scrotum, of filarial origin in an Arab. Case and 
 photograph of Dr. Raynaud, Algiers. 
 
 The thighs are invaded from below upward, or consecutively to 
 elephantiasis of the external genital organs. 
 
 The latter constitute the second seat of election of elephantiasis. 
 In men, hypertrophy of the sheath of the penis may transform this 
 organ into a pear-shaped mass 20 to 40 cm. in length. When the 
 scrotum is the seat of elephantiasis, it may become as large as or 
 larger than an adult's head (Fig. 115), engulfing the penis; its surface 
 is smooth or verrucose. The name lymph-scrotum is applied to 
 elephantiasis of the scrotum with very pronounced lymphatic 
 varicosities. 
 
364 
 
 CUTANEOUS HYPERTROPHIES 
 
 In women, various portions of the vulva, especially the labia 
 niajora and minora, or only one of these, assume an enormous size; 
 the condition may simulate a myxoma (Fig. 116). I have elsewhere 
 mentioned the syndrome of esthiomene, which maybe brought about 
 by a variety of vulvar ulcerations accompanied by elephantiastic 
 hypertrophy. 
 
 Fig. 116. — Elephantiasis nostras of the vulva. 
 
 In the groins, elephantiasis gives rise to general tumefaction with 
 enormous lymphatic dilatations, known as aderto-lymphocele. 
 
 Fig. 1 17. -Elephantiasis of the face; elephantiastic edema of the eyelids, following 
 repeated attacks of erysipelas. 
 
 The upper extremities which are rarely attacked separately, are 
 transformed into monstrous sausages, constricted at the elbows 
 and the wrists. 
 
ELEPHANTIASIS 365 
 
 In the face, elephantiasis generally appears in the form of per- 
 manent bloating, a flabby but non-plastic edema, usually consecu- 
 tive to recurrent erysipelas. It may occupy the entire face and 
 be accompanied by lymphatic varicosities of the mouth. In other 
 cases it predominates in a given region, for example at the ears. 
 The eyelids, especially the lower lid, may become the seat of a 
 smooth pseudo-myxomatous globular swelling (Fig. 117). On the 
 lips, nose and chin, elephantiasis is usually secondary to the lesions 
 of lupus or leprosy, or especially sclero-gummous syphilides; the 
 resulting facies is called leontiasis. 
 
 It is fairly common, in all kinds of elephantiasis, for several 
 territories to be invaded at once or consecutively, for instance a 
 lower limb and the genital organs or a leg and an arm, etc. 
 
 At the borders of the elephantiastic regions, the transition into 
 the normal condition is always gradual; the intermediate zone is 
 edematous and soft. 
 
 The corresponding glands are always altered, usually indurated 
 and involved in the general swelling ; they may be impalpable in the 
 fibro-edematous swelling. 
 
 Pathological Anatomy.- — The elephantiastic tissues are tough, 
 resistant under the knife or merely firm, but always translucid, of 
 gelatinous appearance, gorged with plasma which escapes abundantly 
 from the cut surface. The cutis, the thickness of which may reach 
 2 or 3 cm., the hypoderm two or three times thicker, with the 
 muscles and aponeuroses, etc., form a single lardaceous mass which 
 extends as far as the bones which also are sometimes hyperplastic. 
 The vessels, especially the veins and the lymphatics, are seen 
 gaping in cross-sections, producing a riddled or cavernous appear- 
 ance. 
 
 The microscope shows in all cases a new formation of young or 
 of fibrous connective tissue, without an elastic plexus, sometimes 
 purely interstitial, sometimes forming besides an additional layer 
 between the corium and the greatly hypertrophied papillae. Between 
 the connective-tissue bundles, the connective cells are hyperplastic, 
 sometimes of giant size; collections of leukocytes and plasmocytes 
 are also met with. The vascular walls are thickened, infiltrated 
 with cells, or sclerotic. The muscles and glands are atrophied. The 
 adipose tissue often seems to be increased. 
 
 Briefly, the inflammatory character of the lesions and on the 
 other hand the venous and lymphatic stasis, are distinctly evident; 
 all the supporting tissues are hyperplastic. 
 
 The corresponding glands are sclerotic, as a rule; sometimes they 
 are found to be transformed into a fibrous shell, invaded by fatty 
 degeneration or into lymphatic cavernous tissue. In secondary 
 elephantiasis, they are often degenerated. In an operation upon 
 
3GG CUTANEOUS HYPERTROPHIES 
 
 tropical elephantiasis of the scrotum, an adult filaria was found 
 in the excised tissues. 
 
 I have repeatedly observed remains of phlebitis obliterans in the 
 large veins supplying the elephantiastic regions. 
 
 Pathogenesis. — The most plausible explanation of the lesions of 
 elephantiasis refers them in the first place to stasis, especially 
 lymphatic but also venous, leading to edema; and to a con- 
 secutive, or rather concomitant, irritation of the connective tissues. 
 ( 'ruveilhier particularly stresses the venous lesions, Virchow, the 
 glandular obstruction. 
 
 Although experimental elephantiasis cannot be arbitrarily pro- 
 duced, it has several times been involuntarily caused in man through 
 the extirpation of a group of suppurating or sclerotic glands, or 
 through paraffin injections which have obliterated a lymphatic 
 plexus. 
 
 Various infections or neoplastic processes may result in the con- 
 ditions essential to the development of elephantiasis; local tuber- 
 culosis, tertian syphilis and cancer may become complicated by 
 secondary elephantiasis. 
 
 The relation of filariasis to the endemic elephantiasis of tropical 
 countries is no longer questioned, but superadded infections may be 
 suspected of playing a certain part in such cases. 
 
 The relations of elephantiasis nostras to ordinary lymphangitis 
 had long been known when Achalme and Sabouraud demonstrated 
 the presence of the streptococcus in the elephantiastic tissues in the 
 course of acute attacks. Later it was shown that other micro- 
 organisms may take its place. 
 
 The infection is exogenic and primary, or it may be secondary, 
 for instance to ulcerative lesions, in other cases it seems to be 
 endogenic, derived from remote foci, or lurking for a long time, even 
 indefinitely, in a state of latent infection in territories which have 
 once been invaded. Those who are familiar with the lymphangitic, 
 phlebitic and glandular lesions of streptococcus and of erysipelas in 
 particular, will not be surprised to see that elephantiasis may result 
 therefrom. 
 
 Treatment. — An acute attack should be treated, like all cases of 
 lymphangitis, by absolute rest, with elevation of the affected limb 
 and moist dressings, or applications of ichthyol, thiol, etc. 
 
 Elephantiasis in the sluggish state must first be cleansed from the 
 crusts and coatings by means of baths, fomentations, and oily 
 inunctions; ulcers should be disinfected and dressed. Next, always 
 assisted by rest in the position most favorable to decongestion of the 
 affected part, systematic massage should be employed with com- 
 pression by cotton-padded bandages, or preferably elastic bandages, 
 proceeding cautiously and closely watching developments. The 
 
ELEPHANTIASIS 367 
 
 results obtained by these methods are sometimes remarkable, but 
 nevertheless as a rule incomplete. Castellani adds to the elastic 
 compression, which must be kept up night and day for three to six 
 months, daily injections of 2 to 4 cm. of fibrolysin. In case of 
 syphilis, specific treatment would of course be indicated. Anti- 
 streptococcus serum seems to be of slight efficiency. In hard 
 elephantiastic edemas, Denis recommends injections of "du Breuil" 
 water. 
 
 When sclerosis predominates and compression is no longer suc- 
 cessful, galvanic electricity, advocated by Moncorvo and Silva da 
 Araujo, is very valuable for softening the indurated tissues. The 
 negative pole is represented by a bath in which the affected part is 
 placed, or by moist compresses in which it is wrapped, the posi- 
 tive pole being applied to the healthy tissues; strong currents are 
 required. Still better results can undoubtedly be accomplished by 
 means of ionic medication. Attempts to perform "lymphangio- 
 plasty," through subcutaneous filiform drainage, are very variably 
 estimated. 
 
 Some cases of elephantiasis, notably of the scrotum and penis in 
 hot countries, constitute a disease against which extensive surgical 
 ablations are the only efficient measure. In case of filariasis, injec- 
 tions of arsenobenzol will cause the filarial to disappear from the 
 blood, but they do not seem to act upon the elephantiasis. 
 
 Elephantiasis Nostras. — This is observed in adults of all ages, 
 and in both sexes. 
 
 In a considerable number of cases, the portal of entrance of the 
 infection, usually streptococcic, is obvious — a scratch, an incised 
 corn, or any kind of erosion. The first lymphangitis may be of 
 violent, abrupt onset, with edematous and painful progressive 
 redness, long red streaks, glandular swelling and associated febrile 
 malaise. Sometimes, especially in the face, it appears as a typical 
 erysipelas. All the symptoms subside after a few days, but there 
 follow repeated, sometimes rhythmical recrudescences, following 
 traumatism, fatigue, exposure to cold, or ordinary causes; these 
 are often less violent but more protracted than the first attack. 
 The tumefaction, which had not entirely subsided before, becomes 
 established and gradually increases. 
 
 In other cases, the initial lesion remains unknown. The attacks 
 are afebrile and are marked only by heaviness or tenderness of the 
 affected region, articular pains, etc. The lymphangitis in this case 
 is not apparent, but nevertheless everything points to the occur- 
 rence of a lymphatic obstruction. 
 
 Such an obstruction appears evident in a third group where the 
 elephantiasis develops as the result of an adenopathy. Tuberculosis 
 of a group of glands, cancerous adenopathy, sclerotic adenopathy 
 
368 
 
 CUTANEOUS HYPERTROPHIES 
 
 following upon syphilis, a suppurating glandular in Ha mm at ion, or 
 surgical extirpation of glands, may lead to elephantiasis of the cor- 
 responding territories. One of the lower limbs, or the genital organs, 
 or both these regions together, will be involved in the case of inguinal 
 adenopathy (Fig. 118); the upper limb, as a sequel to cancerous 
 axillary adenopathy, which is so common 
 in the course of cancer of the breast; the 
 face, in the case of submaxillary adenop- 
 athy. 
 
 Gradually, without inflammatory attacks, 
 the above outlined clinical picture develops; 
 lymphatic varicosities, lymphoceles and 
 lymphatic fistulas are especially frequent 
 and important in this group of cases. 
 
 Secondary Elephantiasis or Elephanti- 
 astic Conditions. — This is by far the most 
 common form of elephantiasis in our 
 climates. In these cases, sclerotic edema, 
 then elephantiastic, usually verrucous 
 pachyderma develop in connection with a 
 local lesion of which they represent a com- 
 plication. 
 
 Elephantiastic conditions are observed 
 in the course of cutaneous tuberculosis and 
 especially lupus of the limbs (elephantiastic 
 lupus); in tertiary syphilis, especially as 
 the result of recurrent gummous infiltra- 
 tion on the limbs or on the genital organs, 
 also at the circumference of the mouth and 
 nose (syphilitic leontiasis); in leprosy, when 
 incurable ulcers are present; in the course 
 of leg ulcers, where one may observe the 
 formation not only of a callous cushion, 
 but also of monstrous deformities (Fig. 
 114), above the ulcer or its cicatrix. 
 
 The pathogenesis of these elephantiastic 
 conditions is often complicated, so that it 
 would not be justifiable to divide them into 
 tuberculous, syphilitic, etc., elephantiasis. 
 The specific process undoubtedly invades the lymphatics and veins 
 of the affected region; but in addition, the corresponding glands 
 are degenerated or sclerotic; finally, secondary infection of the 
 ulcerations by the streptococcus or other microbes, whether revealed 
 or not through attacks of lymphangitis, is extremely probable and 
 can be bacteriologically demonstrated in some of the cases. 
 
 Fig. 118. — Elephantiasis 
 nostras of the lower limb 
 with lymphatic varicosities 
 of the scrotum and at three 
 points on the thigh. The 
 lesions in this young man 
 were consecutive to tuber- 
 cular adenopathy of the 
 inguinal glands. These de 
 Guillemin, Paris, 1900. 
 
ELEPHANTIASIS 369 
 
 It is useful to know that after syphilitic chancrous lymphangitis, 
 it is not uncommon to observe a sclerotic edema of the prepuce and 
 sheath, or of a labium majus, undoubtedly due to a specific lymphan- 
 gitis through the spirochete; this lesion may subside more or less 
 gradually under the influence of antisyphilitic treatment. 
 
 Elephantiasis Filariosa. — In many tropical countries, cases of 
 elephantiasis are extremely common; some are probably referable 
 to the various pathogenic factors mentioned above, but in addition 
 there occurs an endemic helminthiasis, known as filariasis, which 
 may give rise to lymphangitis, orchitis, lymphangiectasis, lymph 
 scrotum, filarial abscesses, chyluria, chylous hydrocele and also 
 frequently to elephantiasis. 
 
 ♦ o° o° 
 oo 
 
 J 6 
 
 oo 
 
 Fig. 119. — Filaria sanguinis hominis, surrounded by red corpuscles. Drawn from 
 a fresh specimen prepared by Dr. Jolly. X 300. 
 
 It is caused by the filaria Bancrofti and its embryos, the so-called 
 microfilaria. This worm is a nematode, the adult female, discovered 
 by Bancroft in 1876, measuring 8 to 10 cm. in length, while the male 
 is considerably smaller; they lodge, a few in number, in the large 
 lymph trunks or glands, where the female hatches innumerable 
 embryos which resemble small active eels, about 300^ long, from 
 7 to 9^ wide, enclosed in a glassy sheath. These microfilarias were 
 seen by Demarquay (1863) in a chylocele and by Lewis (1877) in 
 the circulating blood (Filaria sanguinis hominis) where they are 
 found only during the night and should be looked for about mid- 
 night in doubtful cases; in the daytime they withdraw into the 
 pulmonary vessels, according to the observation of P. Manson. 
 
 The disease is transmitted through mosquitoes, which in stinging 
 the patients absorb the embryos; these undergo a metamorphosis 
 in the thoracic muscles of the insect and are then inoculated into 
 other human subjects, where they reach maturity. 
 
 The etiological role of these parasites in elephantiasis seems to 
 rest on the very frequent association in the same countries and 
 24 
 
370 CUTANEOUS HYPERTROPHIES 
 
 in the same patients, of monstrous pachydermas and other symp- 
 toms of filariasis. It must be admitted, however, that numerous 
 filaria-bearers have no elephantiasis and that on the other hand 
 in many elephantiasis cases in hot countries, the embryos cannot be 
 demonstrated in the blood. 
 
 It is accordingly possible that the obstruction of the large lym- 
 1 >hatic trunks by the adult filaria, or of a large number of lymph vessels 
 by ova which have not reached maturity (P. Manson), or the inva- 
 sion of the embryos into the connective-tissue interstices of the 
 affected parts, are sufficient causes of the elephantiasis; it is also 
 possible that the filariasis constitutes merely a predisposing cause of 
 ordinary elephantiasis. 
 
 At any rate, filarial elephantiasis is observed in infected countries, 
 in all races, in both sexes, at all ages, but especially in adults. In 
 95 per cent, of the cases it occupies the lower limbs, one or both; 
 very frequently also the external genital organs. It proceeds by 
 lymphangitic or erysipeloid attacks, often with fever (filarial fever), 
 with general symptoms and adenites, precisely as in elephantiasis 
 nostras. In one case, Le Dantec was able to isolate and cultivate 
 a "dermatococcus." 
 
 The symptomatic shades which distinguish tropical elephantiasis 
 from the domestic form consist of its often excessive development 
 and its frequent association with enormous lymphatic varicosities 
 or other filarial manifestations. 
 
 Congenital Elephantiasis. — Under this term are united a long 
 array of heterogeneous cases in which an enormous hypertrophy of 
 a portion of the body was demonstrated at birth or shortly after- 
 ward. There is reason to suspect the following conditions, in differ- 
 ent cases: 
 
 Giant lipomatosis; diffuse angiomas and lymphangiomas; lym- 
 phatic edemas due to tumors or malformations; and finally, neuro- 
 fibromas or diffuse fibromatosis. 
 
 According to Moncorvo, who has made a special study of this 
 subject, there exists a genuine fetal elephantiasis, due to intra- 
 uterine lymphangitis, the pathogenic agent having penetrated by 
 the placental- route. Filaria have never been found in the affected 
 children. 
 
 The localization is arbitrary; the hypertrophy affects a limb or 
 part of a limb, the eyelids, the tongue, etc. 
 
 Congenital macroglossia, for instance, which is one of the most 
 peculiar forms, has been referred to a variety of conditions in differ- 
 ent cases, fibrinous or muscular hypertrophy, cavernous angioma 
 and especially diffuse lymphangioma. 
 
 The subject is complex and as yet imperfectly understood. 
 
NON-ELEPHANTIASTIC HYPERTROPHIES 371 
 
 NON-ELEPHANTIASTIC HYPERTROPHIES. 
 
 Not all regional or diffuse hypertrophies should be described as 
 elephantiasis. As has just been seen, the diagnosis may present 
 serious difficulties in the newborn; this is not generally the case in 
 adults, except in rare cases. 
 
 By means of careful and systematic palpation, it may be recog- 
 nized that there exists no true pachyderma in edema, in obesity, in 
 the case of lipomas even when regional and symmetrical, in adeno- 
 lipomatosis, in adiposis dolorosa of Dercum, in acromegaly, etc., 
 which accordingly do not belong to the scope of this book. 
 
 More closely related to elephantiasis, although they remain 
 distinct by their clinical and anatomical features and by their 
 pathogenesis, are the following diseased conditions: 
 
 Nemo-arthritic Pseudo-elephantiasis. — The observations to which 
 this name, due to Mathieu, is applied, as well as that of trophedema 
 of Meige (1898) are difficult to interpret. 
 
 Extensive regional edemas, which become chronic and fibrous, 
 occur in the absence of a demonstrable cause; in other cases, hard, 
 non-depressible swellings are present from the start. The seat of 
 predilection of this affection is on the lower limbs, only one of which 
 may be involved, or both may be symmetrically swollen and 
 enlarged; the genitals escape, as well as the foot, except sometimes 
 its dorsal region. The trophedema may likewise affect the upper 
 limbs and even the face. 
 
 At first sight the appearance is that of elephantiasis; but the 
 skin always remains smooth, of normal color, without verrucosities 
 or lymphatic varices; but it is adherent, and cannot be folded or 
 indented. 
 
 The onset is often marked by severe neuralgic pains, or by 
 spasms, without inflammatory symptoms; exaggerated tendon 
 reflexes were noted by me in two cases. All evidences of a disease 
 of the nervous system is absent as a rule. 
 
 The affection progresses or remains stationary, always lasting 
 many years without other disturbance than an impairment of 
 mobility; it may improve under the influence of thyroid treatment, 
 massage and compression, or sometimes actually disappear. 
 
 The pathological lesions are not well understood. It is not 
 known if this disease is comparable to myxedema, constituting an 
 incomplete or abortive form, or to the diffuse hypertrophies which 
 sometimes accompany infantile paralysis or paraplegia. It seems 
 to be related to the following type: 
 
 Neuro-arthritic Pseudolipoma. — Potain, Bucquoy, Mathieu and 
 others, have described under this name tumefactions having a 
 supraclavicular and symmetrical seat of election, supposed to be 
 
372 CUTANEOUS HYPERTROPHIES 
 
 angioneurotic edemas, plastic at the onset, then fibrolipomatous, 
 indistinctly outlined. Their true character has not yet been 
 established. 
 
 Dermatolyses. — These malformations are always partial, usually 
 congenital, but sometimes developing a considerable time after 
 birth. They consist of thickening and well marked loosening of the 
 skin in certain regions of the body. 
 
 Alibert recognized palpebral, facial, cervical, ventral and genital 
 dermatolyses; still others may be observed, notably on the lower 
 limbs. The denominations pachydermatocele (Mott) and chaJazo- 
 derma (Bazin) are less commonly employed. 
 
 The relaxed skin forms large, thick and flabby folds which are 
 dragged by their own weight so as to cover the subjacent parts, 
 sometimes hanging down like an apron. 
 
 The majority of the cases of this group are probably referable to 
 v. Recklinghausen's disease, in which the "major tumor" is repre- 
 sented by the pachydermoceie. Swollen and nodular nerve-strands 
 have been demonstrated therein (plexiform neuroma) and in several 
 instances the patients were at the same time the bearers of smaller 
 mollusca. 
 
 Ordinary relaxation of the skin due to pregnancy, senility, etc., 
 is not true dermatolysis. 
 
 Cutis Hyperelastica, or Cutis Laxa, is a different malformation in 
 which the skin of certain regions, without being distended or loos- 
 ened, is of a doughy consistence, extraordinarily distensible, and 
 suddenly resumes its place when liberated after stretching. Some 
 of the "rubber men," exhibited in side-shows, can pull the skin of 
 the neck up to the forehead, etc. 
 
 Myxedema. — Myxedema, or pachydermia cachexia, is a general 
 dystrophy dependent upon thyroid insufficiency. 
 
 It is observed under a great variety of conditions, especially in 
 women (Gull, Ord), or as a sequel of total extirpation of a goitre 
 {cachexia strumipriva, J. Reverdin of Geneva and Kocher of Bern), 
 also in children (myxodematous idiocy of Bourneville); the latter, 
 which in combination with goitre constitutes cretinism, is known to 
 be endemic in certain mountainous regions. 
 
 The principal symptoms are of a general kind: mental sluggish- 
 ness, slowness of movements and of speech, anorexia, a retarded 
 pulse, a lowered temperature and a sensation of chilliness; in 
 children, idiocy and an enormous retardation in growth. Instead 
 of dwelling upon these, I shall pass on to the external symptoms: 
 
 The integument is swollen, waxy white, dry, scaly, indurated and 
 docs not retain the imprint of the finger. The hairs fall out, the 
 sebaceous and sweat secretions are suppressed. 
 
 The appearance is characteristic: the bloated "full-moon" face, 
 
NON-ELEPHANTIASTIC HYPERTROPHIES 373 
 
 the hanging cheeks, the large nose, the swollen and open lips, con- 
 vey an impression of imbecility. The buccal mucosa may be swollen 
 and waxy. The neck is enlarged and the thyroid gland is not demon- 
 strable on palpation. An analogous condition exists on the trunk 
 and especially on the extremities, which may present a pseudo- 
 elephantiastic appearance. 
 
 The hypothyroidism of the menopause, which is very common, 
 gives rise to a greatly attenuated picture of myxedema. 
 
 The anatomical lesions, aside from atrophy, degeneration or 
 sclerosis of the thyroid gland, in the integument consist of fibrous 
 proliferation, with hypertrophy of the adipose layer. 
 
 I do not believe that " an infiltration of the tissues by a substance 
 analogous to mucin" has been observed since Ord. But the follow- 
 ing have been demonstrated: Collections of inflammatory cells 
 (Virchow), which I was enabled to find also in experimental myxe- 
 dema in animals; rarefaction with degeneration of the connective- 
 tissue bundles; and a degeneration of the elastic fibers as in senile 
 change. 
 
 The treatment with thyroid substance is imperative and yields 
 remarkable results, but must be kept up indefinitely. Thyroid 
 grafting has recently been tried. 
 
 Rhinoscleroma. — This is a progressive hypertrophic affection, 
 described by Hebra and Kaposi, restricted to the region of the nose 
 and upper lip; it is endemic in certain countries, such as Galicia, 
 Hungary, southwestern Russia, etc., and is of microbic origin. [It 
 is rare in America and almost always of exotic origin.] 
 
 The lesions usually begin on the septum of the nasal fossse, or at 
 the columella and the upper lip in the form of solid elevations, with 
 a smooth and tense epidermis, of a red, pink, or pale color, which 
 develop into a tumor of cartilaginous hardness resembling a keloid. 
 
 The disease affects both nasal fossa?, which become obstructed; 
 the velum of the palate, causing retraction of the uvula; the 
 pharynx and larynx, resulting in stenosis; and even the trachea. 
 
 The course is very slow and may lead after twenty years or more 
 to death from pulmonary complications. The disease attacks 
 youthful or adult individuals, especially of the indigent classes. 
 
 An encapsulated bacillus, the Frisch bacillus, closely related to, 
 if not identical with the pneumobacillus of Friedlander, is held to 
 be responsible and, it is claimed, has been found in pure culture in 
 the glands, which according to Rona are frequently swollen. 
 
 The lesions consist of a sclerogenic cellular infiltration, containing 
 large hyaline cells, the origin of which is referred by some to a 
 cellular degeneration and by others to a degeneration of the bacilli 
 themselves. 
 
 The surgical treatment is usually followed by recurrence; caustic 
 
:!74 
 
 CUTANEOUS HYPERTROPHIES 
 
 topical applications and interstitial injections arc unreliable pro- 
 cedures. Radiotherapy is indicated and has furnished encouraging 
 results. 1 1 have definitely cured one ease by means of ./'-ray. 
 Autogenous vaccines should be tried in eases not amenable to 
 radiotherapy.] 
 
 Rhinophyma and Hypertrophic Acne. The nose is sometimes the 
 seat of a psendo-elephantiastie hypertrophy, giving rise to special 
 clinical conditions in this region. 
 
 Although without actual gravity and hardly even inconvenient, 
 it is readily understood that deformities of this kind are extremely 
 distressing to the patients. 
 
 § 
 
 
 
 : 
 
 
 ^P*T 
 
 % 
 
 
 
 ''■''■ "&)wilBP^ 
 
 
 ■^'''^^k 
 
 ^ 
 
 •*-£m$t- : §4jj^^^^ 
 
 
 -Ifj^^^ 
 
 Fie;. 120. — Acne hypertrophica of the nose. 
 
 These hypertrophies of the nose, more common in men than in 
 women, do not occur until about the fiftieth year and affect only 
 very kerotic individuals, who have suffered from acne when young; 
 often they are complications of so-called " copper-nose." The course 
 is progressive and very slow. 
 
 Two forms can be distinguished and are sometimes associated: 
 In the glandular variety — or hypertrophic acne of Vidal and 
 Leloir — the skin is thickened, but of a normal color; the sebaceous 
 pores are dilated and funnel-shaped; the point of a probe may be 
 
NON-ELEPHANTIASTIC HYPERTROPHIES 375 
 
 introduced and a large amount of a sebaceous, vermicular and fetid 
 material squeezed out. 
 
 In the fibrous angiectatic variety — or rhinophyma — the cutaneous 
 surface is of a purplish red color, lumpy, furrowed by large-sized 
 varicose venules, riddled with sebaceous orifices and often dotted 
 with pustules. 
 
 In both forms, the nose is either uniformly increased in size, 
 or covered with globular protuberances (Fig. 120) or even with 
 pedunculated tumors attached to the lobule or the nostrils, some- 
 times reaching or exceeding the size of an egg and hanging down 
 to the chin. Their consistence is flabby, uneven, gelatinous. The 
 cheeks are sometimes invaded by an analogous proliferation. The 
 boundaries of these changes are not well marked. 
 
 The lesions of hypertrophic acne consist of an enormous hyper- 
 trophy of the sebaceous glands, with an ampullary dilatation of 
 their excretory duct. In rhinophyma, on the contrary, hyperplasia 
 of the connective tissue and of the vascular and lymphatic plexus 
 predominate. Disseminated foci of cellular infiltration are regularly 
 present. Complication with epithelioma has been repeatedly noted. 
 
 The treatment demanded on account of the disfiguring character 
 of these affections may consist at the onset of ichthyol applications 
 and warm astringent lotions, or strong sulphur lotions, which in 
 combination with massage and expression of the sebaceous material, 
 may improve the condition of the affected parts. 
 
 It is preferable to interfere actively, without loss of time, by 
 means of the galvanocautery, by scarifications, or electrolysis. 
 
 In the presence of a considerable hypertrophy, the operation 
 known under the name of decortication, performed with the thermo- 
 cautery or the bistoury, yields excellent results; grafts are unneces- 
 sary, for the remnants of the divided glands become centers of 
 epidermic renewal ; it is essential not to excise too deeply. Recur- 
 rences have not been recorded. 
 
CHAPTER XIX. 
 FOLLICULOSES. 
 
 The forms of dermatological lesions which still remain to be 
 studied in the first portion of this book have the peculiar feature of 
 being characterized, not by the nature of the pathological process, 
 but by its localization. 
 
 As folliculoses I designate those pathological processes which 
 affect exclusively, or with evident predilection, the pilo-sebaceous 
 follicles. 
 
 The syndromes to which they give rise assume a certain appear- 
 ance of kinship by virtue of this localization. It is always relatively 
 easy, even for a beginner, to determine whether a cutaneous affec- 
 tion is follicular or not ; it is far less simple, when dealing with a 
 follieulosis, to distinguish its pathological character. This con- 
 sideration in my opinion fully justifies the arrangement adopted 
 in the following: 
 
 Pilo-sebaceous Follicles. — The pilo-sebaceous follicle is an invagi- 
 nation of the epidermis; its floor, raised as a papilla, gives insertion 
 to the hair, which is secreted by this papilla; a lateral diverticulum, 
 the sebaceous gland, secretes a fatty material, the sebum. 
 
 This follicle, of epithelial structure, projects into the derma, its 
 extremity sometimes reaching the hypoderm. It is encased in a 
 fibrous follicular sac, into which a muscle with smooth fibers, the 
 erector pill, is usually inserted. 
 
 Two details in the structure of the follicle are of special interest 
 for the dermatologist. 
 
 The first concerns the difference in its constitution above and 
 below the opening of the sebaceous gland. Whereas in the deep 
 portion the invaginated epidermis undergoes various modifications 
 which transform it into the epithelial sheaths of the hair, it pre- 
 serves in the external, less extensive portion, exactly the same char- 
 acteristics as on the surface of the skin. This superficial portion, 
 the follicular collar, also known as the ostium of the follicle, the pore, 
 or on account of its usual form, the follicular funnel, participates 
 therefore in the pathology of the surface epithelium. 
 
 Moreover, the follicular pore is especially exposed to repeated 
 traumatism, through rubbing and scratching, because the hair 
 which traverses it acts as the arm of a lever. 
 
 Finally, it represents an ever-ready receptacle for dust, irritative 
 
ACUTE SUPPURATIVE FOLLICULI TIDES 377 
 
 matter of occupational, pathological or therapeutic origin and 
 notably for microorganisms, pathogenic or saprophytic, to which 
 it offers shelter. It has very properly been said that the follicular 
 funnel is the flaw in the epidermic armor. 
 
 Another noteworthy anatomical fact is that the pilo-sebaceous 
 follicle is surrounded by a network particularly rich in bloodvessels 
 and nerves; with the result that the phenomena of reaction are 
 easily elicited and well-marked. 
 
 The pilo-sebaceous follicles are distributed, in variable numbers 
 and dimensions in different regions, over the entire integument, 
 with the sole exception of the palmar, plantar and ungual regions 
 and the semimucosse. It is therefore an incorrect expression to 
 speak of areas provided with fine downy hairs as glabrous or smooth, 
 in contradistinction to hairy regions supplied with coarse hairs. 
 
 Folliculoses. — The affections of the follicles, which I group 
 under this heading, are very numerous and variegated. Some con- 
 cern the localization of a skin disease which occurs elsewhere, while 
 others are pathological conditions peculiar to the follicles. 
 
 In the former case, the follicular localization may be accidental, 
 as it were, without lending a special feature to the dermatosis; 
 this is the case, for instance, in follicular purpura, in psoriasis, in 
 soft chancre, etc. It seems to me superfluous to dwell upon these 
 possible peculiarities. 
 
 In other cases, the follicular localization of the dermatosis is elective 
 and visibly modifies the clinical picture; the affections of this kind 
 (for example: follicular pyodermatitides, follicular syphilides, etc.), 
 must necessarily figure in this chapter. 
 
 However, the preceding data do not furnish a sufficient basis of 
 classification. The mode of grouping the folliculosis which seems to 
 me most in conformity with clinical facts, distinguishes between : 
 
 1. Acute suppurative folliculitides. 
 
 2. Follicular complications of kerosis, namely seborrhea and the 
 various acnes which result from the same. 
 
 3. Depilating folliculoses. 
 
 4. Subacute folliculoses , among which belong the follicular locali- 
 zations of eczematides, syphilides and tuberculides. 
 
 5. Pityriasis rubra pilaris, which one is inclined at present to 
 connect with the preceding group. 
 
 6. Follicular keratoses. 
 
 ACUTE SUPPURATIVE POLLICULITIDES. 
 
 These are subdivided into two groups: those which are purely 
 pyococcic, namely due to the ordinary microbes of suppuration; 
 and those which are trichophytic. 
 
378 FOLLWULOSES 
 
 They manifest themselves in the form of pustules pierced by a 
 hair through their center, more or less superficial or deep, of 
 variable size and surrounded by a congestive halo. 
 
 It has been shown above that Bockhardt's impetigo or staphylo- 
 coccic impetigo, tends to assume the form of superficial and intra- 
 epidermic osteofollicular pustules; it is unnecessary to repeat its 
 description. 
 
 Not uncommonly the superficial suppuration is accompanied or 
 complicated by the formation of a minute abscess, situated more 
 deeply along the follicle and due to the penetration of the pyogenic 
 microbe (Plate II): this condition is notably present in the case of 
 folliculitides of the regions with coarse hairs, known under the old 
 name of .sycosis (from gvkov = ?l fig.). There are two varieties of 
 sycosis: one simple or pyococcic, the other trichophy tic ; the latter 
 will be described together with the trichophytic folliculitides. 
 
 Furuncle and carbuncle are acute staphylococcic folliculitides, deep 
 from the start, with extensive inflammation, terminating in partial 
 necrosis and suppuration. The primary follicular localization, some- 
 times very apparent, is less evident in other cases. The reader is 
 referred for their description to the chapter on the pyodermati- 
 tides. 
 
 Acnes are often pustules, but they represent the inflammation of 
 a preliminarily altered follicle and will be discussed in a subsequent 
 section . 
 
 Sycosis Simplex. — The acute suppurative staphylococcic follic- 
 ulitis of hairy regions, more particularly the beard, give rise to a 
 symptom-complex, commonly designated under the name of sycosis 
 simplex, vulgaris, or non-parasitic, in contradistinction to tricho- 
 phytic sycosis. 
 
 Aside from the moustache and the beard, simple sycosis is met 
 with at the pubis and in the axilla? in both sexes and on the hairy 
 seal]) in children. 
 
 The peripilar pustules, deep from the start or becoming so later, 
 are scattered irregularly or they may be agminated. Sometimes they 
 begin as follicular papules or as tuberous elevations or as more or 
 less deep and extensive soft infiltrations, causing a sensation of 
 tension, heat or shooting pains and suppurating only secondarily; 
 often the suppuration is primary and early. The affected regions 
 become covered with yellowish or brownish crusts, under which 
 the skin is reddened, eroded and thickened; pressure upon them 
 causes pus to escape from the enlarged follicular orifices. 
 
 A long while before falling out spontaneously the hairs can be 
 pulled out easily and painlessly with forceps or with the fingers; 
 they come out with their root surrounded by a gelatinous, trans- 
 lucid or opalescent sheath, which is their epithelial sheath infil- 
 
ACUTE SUPPURATIVE FOLLICV LI TIDES 379 
 
 trated with pus. This sign, which is typical of an involvement of 
 the deep portion of the follicle, is absent in osteofollicular impetigo ; 
 it suggests that the papilla may be destroyed by the suppuration, 
 with the result of permanent alopecia, although this is usually not 
 the case. 
 
 Simple sycosis, following upon impetigo, furuncle, panaris, coryza 
 or an infection by means of the razor, is spread from one place to 
 another and carried to a distance by means of the fingers or toilet 
 articles [especially towels]. The deep, intradermic seat of the 
 affection, moreover, renders it rather inaccessible to therapeutic 
 agents, which explains its obstinate, frequently chronic character 
 and its tendency to recurrence. Cases of sycosis of the beard of 
 many months' or even years' standing are met with. 
 
 The topography of the lesions permits a separation into several 
 clinical types: 
 
 Sycosis of the beard (mentagra of Alibert), usually symmetrical, 
 occupies the lower portion of the cheeks, whence it spreads upward 
 toward the temples and downward to the subhyoid region, some- 
 times reaching the chin. 
 
 Sycosis of the mustache, often situated laterally under one nostril 
 before becoming bilateral, is practically always connected with a 
 lesion or infection of the corresponding nasal fossa. This mani- 
 fests itself by chronic coryza, a habitual mucous or mucopurulent 
 nasal discharge and ordinarily gives rise at the same time to follic- 
 ulitis of the nasal fossae and ciliary blepharitis or phlyctenular 
 conjunctivitis through an ascending infection. It is noteworthy 
 that trichophytic sycosis, on the contrary, is extremely rare in the 
 region below the nostrils. 
 
 The beard and moustache may be invaded, as a whole, in stru- 
 mous or exhausted individuals, convalescents from serious diseases 
 or even in apparently healthy men in whom all pus infections find 
 an especially favorable soil and tend to last indefinitely in conse- 
 quence of an unexplained predisposition. 
 
 In the pubic or axillary region the suppurative folliculitides 
 develop especially under cover of uncleanliness and neglect and 
 sometimes after scabies. Often, as also in the case of the beard, 
 they become superimposed on a seborrheic or artificial eczema. 
 
 The condition sometimes described as eczema pilaris is merely 
 an eczema of the hairy regions complicated by a peripilar impeti- 
 ginization or by staphylococcic folliculitis. 
 
 On the hairy scalp the folliculitides are observed chiefly in school- 
 children. Pediculosis and various traumatisms are common caus- 
 ative factors. There may be a rapid and profuse outbreak of sup-- 
 purative folliculitis over a part of the scalp or over the entire scalp, 
 as the sequel of removal of hairs with the forceps, painting with 
 
380 FOLLICULOSES 
 
 iodin tincture, application of salves, etc., in the course of treatment, 
 for instance, of an attack of tinea. 
 
 The treatment of sycosis vulgaris is likely to be tedious. In the 
 first place the diagnosis must have been positively confirmed by 
 the microscopic examination of the hairs, showing the absence of 
 the trichophyton. 
 
 The rule is to stop the use of the razor, to cut the hairs short with 
 scissors, to clean the crusted surfaces with sprays or moist dres- 
 sings, to pull out the hairs which are easily detached, to empty the 
 pustules and pack them several times daily with absorbent cotton 
 soaked in "eau d'Alibour" or in resorcinated or camphorated 
 alcohol. 
 
 At the onset, starch poultices are better tolerated than salves or 
 pastes containing calomel, yellow oxide, ichthyol, sulphur, salicylic 
 acid or resorcin, etc., which may be indicated later on. 
 
 Total epilation is sometimes indispensable, notably when the 
 suppuration has reached the depth of the follicle. Preliminary 
 radiotherapy greatly facilitates this and by itself alone often acts 
 very favorably, even in weak doses. 
 
 In obstinate cases, vaccinotherapy is often advantageously 
 employed, either with stock staphylococci or with an autogenous 
 vaccine. Good results are sometimes obtained through the appli- 
 cation of zinc pastes with oil of cade and sulphur or with ichthyol 
 (5 per cent.) containing resorcin (3 to 5 per cent.). 
 
 In the terminal stage, mercurial plasters, sometimes scarifications 
 and the x-rays are effective in the obliteration of the indurations. 
 Correction of hygienic conditions and general tonic treatment must 
 not be neglected; beer-yeast, ferments, arsenic and sulphur water 
 may be of use. 
 
 It is needless to say that from the start everything must be done 
 to extinguish the original foci of the pyococcic infection and especi- 
 ally to cure the chronic coryza in cases of sycosis of the moustache. 
 
 Trichophytic Folliculitides. — The trichophytons which cause sup- 
 purative follicular inflammations are ectothrix trichophytons, that 
 is, they vegetate in the sheath of the hairs and not or very slightly 
 in their interior. Adults are rather more susceptible than children. 
 The parasites are directly or indirectly of animal origin. 
 
 Several clinical types of these trichophytic folliculitides may be 
 described: 
 
 Sycosis trichophytica barbce is due, in the majority of cases, to the 
 trichophyton of horses (trichophyton gypseum); it grows in white 
 cultures and is in itself highly pyogenic. It gives rise to peripilar 
 pustules, with a fairly intense inflammatory zone and a rapidly 
 swelling base; they become agglomerated in red and raised, tuber- 
 ous, firm or even indurated patches or masses from which pus 
 
ACUTE SUPPURATIVE FOLLICU LIT IDES 
 
 381 
 
 escapes through numerous orifices on pressure; sometimes purulent 
 sloughs occur. These patches gradually extend peripherally and 
 new regions at a distance are attacked. The hairs in the middle 
 of the patch easily come out with the forceps and are denuded and 
 dead; it is necessary to look at the margins for hairs still provided 
 with their root-sheath, where it is easier to find the parasitic spore- 
 bearing mycelium under the microscope. 
 
 The lesions are preferably situated in the lower portion of the 
 cheeks or the chin, sometimes at the temples or in the hyoid regions 
 (Fig. 121) ; they are often asymmetrical; in one case I found them on 
 the moustache, an absolutely exceptional location. 
 
 Fig. 121. — Tri exophytic folliculitis of the beard; parasitic sycosis due to tricho- 
 phyton ectothrix. After a cast in the Museum of the St. Louis Hospital, Paris. 
 
 Trichophytic sycosis is observed especially in coachmen, grooms, 
 knackers, veterinaries and horseshoers. 
 
 Trichophytosis of the beard may assume other aspects; that of 
 drier, less suppurative papules or tuberosities; that of red circles 
 or arcs, with white scales and dry epidermic plugs, from which a 
 broken hair emerges, suggestive of keratosis pilaris, etc. This is 
 undoubtedly due to a difference of the trichophytic species; as a 
 matter of fact, a bird trichophyton with rose-colored cultures has 
 
382 FOLLICULOSES 
 
 been demonstrated, a yellow species, the acuminatum, the viola- 
 ceum and so forth. 
 
 Kerion Celsi is the name applied to patches of trichophytosis 
 occupying the hairy scalp of children or adults and similar to those 
 described above in the beard; they are likewise generally due to 
 the trichophyton gypseum. 
 
 The condition, as a rule, consists of one or several nummular or 
 larger, distinctly elevated, rounded disks, with sharply outlined 
 borders of a bright red color; the hairs have fallen or are easily 
 detached; there is a scattering of small white pustules which can 
 be emptied by pressure. 
 
 Folliculitis Agminata, or Leloir's folliculite conglomeree en placards, 
 is the same affection as kerion, but occupies the smooth parts. 
 It is observed at all ages, on the wrists, the forearms and the neck. 
 The red patch, comparable with a macaroon, is covered with a 
 crust or with thick pus; after it has been cleansed it appears inter- 
 spersed with dilated follicular orifices which riddle it like a sieve. 
 There may be several patches of different ages. Their growth is 
 rapid and takes place in a few days. 
 
 The spores and fragments of the mycelium are often difficult to 
 demonstrate in the pus, so that the nature of this affection was not 
 recognized by Leloir. Like kerion, it sometimes lasts for weeks 
 and months, but it may disappear spontaneously. 
 
 The suppurative trichophytic folliculitides leave, as a rule, more 
 or less alopecic cicatrices. 
 
 The diagnosis can sometimes be based on the clinical charac- 
 ters alone, but should always be confirmed by microscopic exami- 
 nation and if possible by culture. The pyococcic folliculitides, 
 even when agminated, do not form as distinctly circumscribed 
 round patches and are more apt to be disseminated. Furuncle 
 and carbuncle have a more pronounced and extensive inflammatory 
 edema, are more deeply infiltrated and much more painful. 
 
 The classic treatment of the trichophytic folliculitides, no matter 
 where the lesions are situated, consists of the careful epilation of 
 the patch and of a peripheral zone of about 1 cm. in width; as 
 the hairs are not brittle, radiotherapy may be replaced by avulsion 
 with the forceps, followed by the application of emollient or anti- 
 septic dressings. It is sometimes necessary to open the deeper fol- 
 licular abscesses with the thermocautery. Finally, the affected 
 surfaces are freely painted with tincture of iodin every other day, 
 or they may be dressed with iodin in vaseline. 
 
 However, all dermatologists have noted that very freely suppurat- 
 ing trichophytoses heal spontaneously, as it were; thorough epila- 
 tion, cleansing and moist dressings or starch poultices are sufficient. 
 This fact is explained either by an immunization or more probably 
 
SEBORRHEA 383 
 
 by the expulsion of the parasites through the suppurative reaction 
 induced by them. 
 
 The precautionary measures necessitated by the contagiosity of 
 this affection must, of course, be insisted upon. 
 
 SEBORRHEA. 
 
 The word seborrhea, which means a flow of sebum, was introduced 
 in 1840 by Fuchs to designate the condition named acne sebacea, 
 by Biett; sebaceous flux, by Rayer and steatorrhea by E. Wilson. 
 
 I have stated above that, in my opinion, seborrhea is one of the 
 principal manifestations of a more general diseased condition which 
 I have named kerosis. 
 
 The meaning of the term seborrhea has been unreasonably 
 extended by authors to the point of applying it to all the other 
 manifestations of kerosis, and even, by Hebra, to pityriasis simplex, 
 thereby leading to the enormous confusion which still prevails as 
 illustrated by the commonly used but highly improper terms of 
 seborrhea sicca (for pityriasis simplex), seborrheic eczema (for eczema- 
 tide) and so forth. 
 
 Seborrhea is an exaggerated sebaceous secretion. A distinction 
 can be made between fatty seborrhea and oily or fluid seborrhea; 
 but there are numerous intermediate conditions. 
 
 Fatty seborrhea [seborrhoea steatosa] is characterized by the dila- 
 tation of the pore and the "collar" of the follicles, especially those 
 with which the larger sebaceous glands are connected, with accu- 
 mulation in the osteo-follicular canal of a substance composed of 
 horny cells, fat and microbes, namely the sebum. 
 
 Sometimes the horny cells predominate and are concentrically 
 arranged, forming the seborrheic utriculus or seborrheic cocoon of 
 Sabouraud; a somewhat greater amount of hyperkeratosis results, 
 in the comedo of acne. 
 
 In other cases, the fat forms with the horny cells a pasty whitish 
 substance, of a butyric acid odor, which can be expressed by squeez- 
 ing between two fingernails, under the aspect of a worm or vermi- 
 celli; this is the seborrheic filament. 
 
 In order to make sure that the condition is really one of seborrhea, 
 instead of a dry follicular keratosis, for example, it is therefore 
 necessary to demonstrate that the fatty material under considera- 
 tion can actually be pressed out from the dilated follicular orifices. 
 This may be done either by compressing the skin between the nails, 
 as mentioned above, or by scraping it forcibly with a glass slide or 
 a blunt scalpel. The substance thus obtained must be fatty; 
 the cocoons or filaments are easily crushed. Under the micro- 
 scope are seen fat drops and horny cells or debris of horny cells; 
 
384 FOLLICU LOSES 
 
 moreover, on staining the specimen with an aniline dye, preferably 
 with thionin, an enormous number of microbes become visible. 
 
 ( Jredit is due to Sabouraud for having shown that these microbes, 
 myriads of which exist in the product of fatty seborrhea, belong to 
 a single species the microbadllus of seborrhea. This is very small, 
 barrel- or rod-shaped, often curved, and not easily grown in cul- 
 tures. Halle and Civatte have demonstrated in my laboratory 
 that it grows much more readily and abundantly in anaerobic 
 cultures. This bacillus was seen by Unna and Hodara, who inter- 
 preted it as the microbe of acne. 
 
 According to Sabouraud, its extreme abundance in pure cultures 
 indicates its pathogenic nature, so that seborrhea should be inter- 
 preted as a parasitic disease. This theory is not acceptable, and 
 it is more likely that this very widespread microbacillus becomes 
 implanted whenever it can live and that its growth is secondary 
 to the seborrhea. 
 
 Seborrhea oleosa [orfluxus sebctceus] manifests itself, in its milder 
 degrees, by a greasy and shining state of the skin, which leaves fat 
 spots on paper; in the advanced degrees, actual drops of oil are 
 seen to dot the integument. It almost invariably coexists with 
 fatty seborrhea. It is very difficult to decide if the fluid fat is 
 really derived from the sebaceous glands instead of from the 
 sweat glands; namely, if the condition is not one of hyperidrosis 
 oleosa. 
 
 The usual distribution of fatty seborrhea is less extensive than 
 that attributed to it by those writers who confuse it with kerosis. 
 Its seat of election is in the center of the face, on the ala? of the 
 nose and in the nasogenial grooves; it is less common in the other 
 regions of the face and on the vertex, rather rare on the thorax and 
 the genitals, exceptional in other kerotic regions. Oily seborrhea 
 is observed on the face, on the hairy scalp and sometimes on the 
 thorax. 
 
 Its etiology merges with the etiology of kerosis. It is practically 
 never observed before puberty. Its relations with sexual develop- 
 ment, genital disturbances and gastric affections are very evident. 
 
 The treatment is also that of kerosis. Locally, less reliance should 
 be placed on fat-removing washes and lotions, containing ether or 
 other ingredients, than on sulphur or camphor, etc. Systematic 
 massage of the skin favors the evacuation of the retained products; 
 its exaggerated employment would be injurious. 
 
 THE ACNES. 
 
 The term acne has been applied, since Willan, to all eruptions 
 which were believed to be due to an affection of the sebaceous 
 
THE ACNES 385 
 
 glands; the clinical appearance, or the related cause or probable 
 character of this affection being specified by an adjective. A reac- 
 tion has set in against this linguistic abuse which led to confusion. 
 
 Seborrhea is no longer described as acne sebacea or oleosa; we speak 
 of keratosis senilis instead of acne sebacea concreta; acne miliaris or 
 milium is a form of epidermic cyst; the acne varioliformis of Bazin, 
 or molluscum contagiosum, is an epithelial tumor; acne rosacea 
 belongs to the chronic erythemas and its complication ; acne hyper- 
 trophica to the hypertrophic dermatoses; acne cornea is a keratotic 
 folliculitis; acne, decalvans is a decalvating folliculitis; acne cachec- 
 ticorum is a variety of tuberculide as acne syphilitica is a form of 
 syphilide. 
 
 There remains a dermatosis which is typical of the genuine acnes, 
 namely acne vulgaris or juvenilis; and, in addition, a few related 
 varieties. 
 
 Acne Vulgaris or Juvenilis. — This is a very frequent complica- 
 tion of kerosis and of seborrhea in particular, manifesting itself 
 as a regional, successive, follicular eruption, especially affecting 
 youthful individuals. 
 
 Acne is not characterized by a single eruptive lesion, but by a 
 polymorphous set of lesions more or less derived from each other; 
 comedones, papulo-pustules, superficial or deep follicular pustules, 
 indurated abscesses, crusts and cicatrices. Besides the cases with 
 perfectly developed lesions, there are very numerous individuals 
 suffering from incomplete acne, with a few comedones and, from 
 time to time, a papulo-pustule. 
 
 A comedo is a small horny mass, with a brown or black top, the 
 size of a pinhead to that of a millet-seed, imbedded in a dilated 
 follicular orifice where it resembles a powder grain. It can be 
 squeezed out by pressure between two finger-nails, in the form of 
 a firm yellowish mass with a black head, followed by a white 
 unctuous filament, resembling vermicelli or a black-headed worm. 
 Sometimes, "double comedones" are encountered, meaning come- 
 dones situated very close together, with a communicating base. 
 
 The comedo results from an ostiofollicular hyperkeratosis; its 
 configuration is that of a small cylinder formed by concentric horny 
 lamellae ; its exposed surface is colored, not by a deposit of dust, but 
 through oxidation of the keratin itself; the cavity from which it 
 may be expressed contains microbacilli in large numbers and sebum . 
 It resists more or less the escape of the sebum, which is retained 
 below; in the face, the demodex folliculorumis not infrequently met 
 with. 
 
 Comedones in variable number, at first imperfectly formed and 
 hardly distinguishable from seborrheic cocoons, later more volum- 
 inous, occur preferably in the face, especially on the nose, the 
 25 
 
386 FOLLICULOSES 
 
 cheeks and the temples, on the chin, the back, the chest and the 
 shoulders and rarely elsewhere. 
 
 When they exist alone they constitute acne punctata, the " black- 
 heads" of the vernacular. 
 
 A little redness and tumefaction around some comedones are 
 characteristic of papular acne. The inflammation is almost invari- 
 ably more intense; the red acuminate elevation, the size of a pin- 
 head to that of a pea, whitens at its apex in two or three days, due 
 to suppuration, the pus may be evacuated or dry up as a crust 
 while the papule collapses, becoming transformed into a brownish- 
 red spot which leaves a minute cicatrix. This constitutes super- 
 ficial pustular acne. It is more or less discrete or confluent and 
 occupies the face, the shoulders and the thorax. 
 
 The pustules develop practically without pain and with hardly a 
 little itching. 
 
 When the papulopustules have the size of a large pea or a bean 
 and are hard, purplish and painful, suppuration being slow but 
 deep and abundant, the condition is described as an acne tuberosa 
 or indurata. In the form known as phlegmonous acne, the dusky 
 red and fluctuating elevations surmount real acneiform abscesses, 
 dermic or hypodermic; sometimes there are cavities with oily 
 contents. 
 
 These different varieties are often associated in the same patient 
 {polymorphous acne) in variable proportion (Fig. 122). In severe 
 cases, the face, chest and back may be covered with lesions in all 
 stages of development and with countless cicatrices of variable 
 size, producing real deformities, so that almost no healthy skin is 
 left. Sometimes the eruption has a tendency to become localized 
 in one of these regions. 
 
 The topography of acne is very specific; it practically never 
 passes below the belt line, nor the upper two-thirds of the arms, 
 nor the margin of the scalp, where it invariably stops. 
 
 The eruption is maintained through uninterrupted crops of new 
 lesions; it is continuous, but with periods of exacerbation in the 
 spring, at the time of menstruation or in connection with errors in 
 diet. [It constitutes about 8| per cent, of all cases seen in derma- 
 tological practice in Ameria.] 
 
 Etiology and Character. — The condition sine qua non of acne is 
 kerosis; individuals having acne always suffer from seborrhea, 
 pityriasis simplex and sometimes from eczematides. A predis- 
 posed soil is present and persists beyond the acne. 
 
 The eruption begins in both sexes at the approach of puberty, 
 flourishes toward the sixteenth and eighteenth year and diminishes 
 between the twenty-second and the thirtieth year; it is not uncom- 
 monly followed by rosacea, baldness or eczematides. 
 
THE ACNES 
 
 387 
 
 The causes of kerosis accordingly predispose likewise to acne; in 
 the first place, the molimina, genital excitement, functional or 
 organic genital disturbances. A very correct observation, fre- 
 quently made, is that acne localized on the chin of young girls 
 or young women almost certainly indicates some utero-ovarian 
 ailment. 
 
 Digestive disturbances, improper diet, gastric dyspepsia and 
 habitual constipation play an equally important part. 
 
 A pale complexion, a "lymphatic" or "arthritic" constitution, are 
 often met with in acne patients, especially those with a kerotic 
 heredity. 
 
 Fig. 122. — Juvenile polymorphous acne. 
 
 As to the determining cause of the eruption, that which trans- 
 forms a seborrhea into acne, it is practically certain that this is 
 primarily of local microbic, infectious origin. This is not an estab- 
 lished fact for comedo, although Sabouraud has shown that the 
 comedo contains in its interior myriads of seborrheic bacilli (the 
 old acne bacillus of Unna and Hodara), and that in its surroundings 
 the bottle-bacillus and cocci are usually present. 
 
 The acne pustule almost regularly encloses, sometimes in enor- 
 mous numbers, staphylococci of various kinds, which are pyogenic; 
 the pustule is only rarely sterile, 
 
388 FOLLICULOSES 
 
 From the benign character of this suppuration, its freedom from 
 pain, its slow development, it may be inferred that the ordinary 
 causative agent is not a virulent staphylococcus, such as the Staphy- 
 lococcus aureus, but more probably the Staphylococcus albus or 
 the staphylococcus growing in gray cultures, the polymorphous 
 coccus of Cedercreutz, or an analogous organism. 
 
 Summarizing, the acne pustule is a folliculitis and perifolliculitis 
 of a follicle obstructed by a comedo and infected by a pyococcus of 
 moderate virulence. The abscess, resulting from the onrush of 
 leukocytes, is primarily situated in the wall of the follicle, under the 
 comedo, destroys this wall in a part at least of its circumference 
 and more or less deeply invades the perifollicular tissue; this explains 
 why it leaves a cicatrix. The sebaceous gland plays only a very 
 subordinate part in the process. 
 
 Treatment. — Both local and general treatment are required. 
 
 Locally, the skin must be kept very clean by means of baths 
 and warm soapy or alcoholic lotions. Camphorated alcohol, at 
 first dilute, camphor and sulphur lotions, sulphuretted or mercur- 
 ial washes, or chlorhydrate of ammonia, yield much better results 
 than salves of any kind. Mild measures must be employed to 
 begin with, for the skin in some cases of acne is extremely irri- 
 table. 
 
 After washing with soap, before applying the selected lotion, it 
 is advisable to squeeze out the comedones from time to time, by 
 systematic massage, pressure with a watch-key, or even by means of 
 a special "comedo punch" and to open the superficial pustules 
 with a flamed needle. These procedures must not be overdone, 
 however, as the eruption is occasionally aggravated in this way. 
 
 In severe and obstinate cases, the rapid exfoliating method is 
 recommended; I have repeatedly been enabled to obtain nearly 
 complete and durable cures with it. Gradual exfoliation is often 
 equally successful, for example with the "strong salve" of Brocq 
 (see Therapeutic Notes) which is allowed to act from five to thirty 
 minutes before a lukewarm wash or bath. The irritation is then 
 soothed by means of a zinc paste. 
 
 In case of indurated or phlegmonous acne, the galvanocautery, 
 if necessary the thermocautery, serve to evacuate the purulent 
 collections and suppress the developing lesions. Radiotherapy, 
 employed as a last resort, sometimes yields very valuable results. 
 
 The internal treatment must aim in the first place at the correction 
 of the general hygiene. The diet must be closely regulated, omit- 
 ting all stimulants, sweets of all kinds, fermentable substances and 
 an excess of meat. The physician must see to the regularity of 
 meal hours, good mastication, the condition of the teeth, regular 
 evacuation of the bowels, which will sometimes have to be secured 
 
THE ACNES 389 
 
 by suitable laxatives. Disturbances of the genitourinary appara- 
 tus must be corrected as far as possible. Exercise, friction of the 
 cutaneous surface and massage contribute to regulate the general 
 circulation. 
 
 L. Jacquet advocated, besides bradyphagia, "massage of the 
 face by petrissage" and facial gymnastics; these measures often 
 prove really efficient. 
 
 The remedies to be recommended are, according to the cases and 
 sometimes successively, arsenic, cod-liver oil, ferruginous agents, 
 ichthyol, beer-yeast and lactic ferments; the latter are sometimes 
 highly successful, sometimes entirely inefficient. Staphylococcic 
 vaccintherapy, or better, inoculation with a mixed autovaccine, may 
 likewise have excellent results or in other cases prove useless. 
 
 [In my experience, juvenile acne may be successfully treated by 
 local measures alone without any regard to the general health. 
 Proper exercise, regular bowel movements and a diet free from 
 excesses of all kinds are good for every one but I have never been 
 able to clearly establish a relationship between juvenile acne and 
 any general abnormalities whatever. One of the most severe and 
 most obstinate cases of acne I have ever encountered occurred in 
 an otherwise perfect specimen of young manhood who lived at the 
 trainer's table and observed the severe regimen required of a mem- 
 ber of a college athletic team. 
 
 My plan of treatment consists of various measures of local anti- 
 septics: washing with soap, avoidance of friction with the towel 
 which serves to spread infection, soaking ten to fifteen minutes 
 with a 1 to 2000 weak alcoholic watery solution of bichloride of 
 mercury (the soap must be thoroughly rinsed off first) and, after 
 washing away the bichloride solution and drying, an application of 
 sulphur paste, i. e., zinc oxide ointment containing 10 per cent, of 
 kaolin and 10 per cent, of precipitated sulphur, to be applied at 
 bed-time. In the morning a soap and water wash. The kerato- 
 lytic action of the paste becomes obvious after five to ten days; the 
 skin feels tight, drawn, as if coated with varnish. This symptom 
 is the signal for omitting the sulphur paste one night and applying 
 instead a soothing and softening cream consisting of 2 per cent, 
 salicylic acid in cold-cream or petrolatum. The next night the 
 paste may be resumed and thereafter must be interrupted by one 
 night of the cream every fourth or fifth day. At the same time 
 it is of primary importance to remove mechanically as many sources 
 of infection as possible; comedones must be squeezed out and 
 pustules evacuated systematically at intervals of three, later seven 
 to ten days. My own experience with vaccines has not been 
 favorable; others, notably Gilchrist and Engman have reported 
 excellent results.! 
 
I'.MI 
 
 FOLLICULOSES 
 
 Medicinal and Occupational Acnes. -These are closely related to 
 juvenile acne and if proof were required, would show the part 
 played by the ingesta as well as 1»\ external irritants in the genesis 
 of this skin disease. 
 
 The iodides and, to a less degree, the bromides produce in some 
 individuals, either from the start or after prolonged administration, 
 an iodide or bromide acne; it- special features are the age of the 
 patient-, the sudden onset and the inflammatory indurated nodu- 
 lar character of the eruptive lesions. These acnes are localized 
 chiefly on the face and the hack and may become associated with 
 other symptoms of iodism or bromism. 
 
 Fig. 123. — Cade oil acne; internal aspect of the right thigh in a case of psoriasis 
 treated with an nil of cade glycerolate. The pustules contained the Staphylococcus 
 
 aureus; cured by means of a soapy salve. 
 
 The various preparations of tar. oil of cade in particular, give 
 rise in those who handle them or apply them to the -kin (in the 
 treatment of psoriasis, for example i to an eruption of reddish- 
 brown papulopustules, centered by a comedo, very much like acne 
 (Fig. 1-':;). 
 
 Mineral oil-, employed for the lubrication of engines, may cause 
 either acute suppurative folliculitides or subacute acneiform fol- 
 liculitides, analogous to tar acne. All these hydrocarbons act 
 apparently by producing an ostio-follicular hyperkeratosis, which 
 retains the pyococci and creates conditions favorable to their growth 
 and to an inflammatory reaction of the integument. 
 
 Chlorin acne presents the features of juvenile acne, although 
 greatly exaggerated, with an extraordinary profusion of comedones 
 and a general distribution over regions which escape in common 
 
The acnes 39 i 
 
 acne; it has been observed in laborers employed in sodium chloride 
 electrolytic works. According to Fumouze (1901) it is due to 
 nascent sodium hypochlorite. 
 
 Acne Necrotica of Boeck (Acne Pilaris of Bazin, Acne Varioli- 
 formis of Hebra, Frontalis, Rodens, etc.) . — This is a disease affecting 
 middle-aged and old persons and presents characteristic lesions. 
 
 The eruption consists of pink or waxy papules the size of a pin- 
 head to that of a small lentil, whose apex very rapidly assumes a 
 yellowish hue, simulating a vesico-pustule and dries to a biconvex 
 brownish-yellow crust; this very adherent crust is embedded in 
 the skin and encircled by a sometimes slightly raised border; its 
 fall is often delayed and leaves an indelible depressed cicatrix. 
 
 Advancing in continuous or intermittent crops, the eruption is 
 situated on the forehead, at the border of the scalp which is often 
 in part invaded, at the temples, in the conchae of the ears, some- 
 times on the nose and in the nasogenial grooves and very rarely on 
 the middle of the back and the chest. The lesions are grouped or 
 disseminated. The affected regions finally become riddled with 
 cicatrices. When left untreated, the affection lasts for years and 
 even indefinitely. 
 
 The histological lesion consists of a dry lenticular necrosis, situ- 
 ated at the orifice of a follicle and comprising the entire thickness 
 of the epidermis and a superficial portion of the cutis; surrounded 
 by an inflammatory zone with thrombosis of the bloodvessels. 
 
 Necrotic acne is distinguished from crusted secondary syphilides 
 by its necrotic character and its cicatrices; from tuberculo-crusted 
 tertiary syphilides, by the absence of induration and by the dis- 
 semination of the lesions. 
 
 Only the microbacillus of seborrhea and various staphylococci, 
 especially the aureus, have ever been discovered in this acne; it 
 is probable that another etiological factor is involved, but it is 
 unknown. Kerosis and seborrhea constitute the necessary soil. 
 
 Appropriate treatment ensures a cure in a few days. The 
 employment of soap and water and of a strong sulphur-cade- and 
 salicylic-acid salve is sufficient; all internal medication is unneces- 
 sary. Sulphur washes or a sulphur salve are recommended for 
 the prevention of recurrences. [I have found soap and water and 
 the application of ammoniated mercury ointment, which is not 
 unpleasant, quite sufficient for a cure.] 
 
 Keloid Acne. — This affection, first described by Bazin — identical 
 with the dermatitis papillaris capillitii of Kaposi — occurs essentially 
 in males and is almost exclusively observed at the nape of the neck, 
 at the border of the hairy scalp and very rarely in the beard. 
 
 It begins as an acuminated papular folliculitis, the size of a millet 
 or hemp seed, which may become pustular; originally disseminated, 
 
392 FOLLICULOSES 
 
 the lesions multiply and become grouped, finally coalescing into a 
 band which occupies the entire posterior border of the scalp. 
 
 This folliculitis is distinguished from the start by its subacute 
 infla.TTiTn fl.tnry character, its very marked induration and a course 
 Leading to the formation of fibrous excrescences. 
 
 The confluence of these lesions results in a horizontal row of 
 agglomerated fibrous tubercles and finally a "cushion" which may 
 have the thickness of a finger, a length of 10 to 15 cm., or even 
 extend from one ear to the other. Cicatricial and smooth on its 
 lower aspect, this cushion bristles on its upper side with hairs 
 arranged in tufts or wisps. On pulling these out, one is surprised 
 by the depth of their implantation. 
 
 The duration of the affection is indefinite; it may be prolonged for 
 fifteen to twenty years, or longer. The cushion slowly extends 
 upward on the occipital region, never in a downward direction, and 
 leaves behind it a pinkish, more or less thickened permanent cicatrix. 
 
 Histology shows a chronic follicular inflammation, noteworthy 
 in that the cellular infiltration is almost exclusively composed of 
 plasmocytes, with a few giant cells; it leads to the formation of a 
 dense hyperplastic fibrous tissue; the process is absolutely different 
 from that of the true keloids, as shown especially by Pautrier and 
 J. Gouin. Its nature is not known and the special microbic agent 
 which is probably present has not been demonstrated. The co- 
 existence of kerosis is invariable. 
 
 Keloid acne is very obstinate to treatment. Antiseptic washes, 
 iodin applications, mercurial ointments, sulphur, naphthol and tar 
 salves are indicated only in the first stage and are rarely sufficient. 
 The best obtainable results are secured by the following method: 
 First, all the active lesions of folliculitis are destroyed with a fine- 
 pointed thermocautery; then the keloid growths are attacked by 
 very deep and repeated scarifications, followed eight or ten days 
 later by a number of radiotherapeutic sessions. 
 
 In well-marked cases, surgical removal is advantageously per- 
 formed, followed by radiotherapy. Extirpation alone is not to be 
 recommended as it is often followed by recurrence. 
 
 CICATRICIAL DEPILATING FOLLICULITIDES. 
 
 The nosographical group of depilating folliculitides, or acne 
 decalvans, is indefinitely outlined and its varieties are still imper- 
 fectly formulated for lack of knowledge of the etiological factors. 
 All the dec]) folliculitides may become depilatory through perma- 
 nent atrophy of the follicle, as in furuncle, favus, keratosis pilaris, 
 sycosis, the acnes and the syphilides. But those under present 
 consideration arc inflammatory, sluggish, progressive, rebellious, 
 
CICATRICIAL DEPILATING FOLLICU LI TIDES 
 
 393 
 
 often agminated and necessarily leave true cicatricial tissue behind 
 them; they are the forms which lead to the cicatricial alopecias. 
 
 Pseudo-pelade of Brocq {alopecia atrophicans of foreign authors) 
 represents the most typical form. It is characterized by alopecic 
 and cicatricial spots or patches, scattered or grouped on an other- 
 wise healthy scalp. These spots have various dimensions and 
 shapes, being sometimes barely lenticular, rounded and very 
 numerous; sometimes several centimeters in diameter, irregular, 
 with geographical outlines; or the two varieties may be associated 
 (Fig. 124). The borders are distinct, without a transitional zone; 
 the surface is wax-white or faintly pink, perfectly smooth, without 
 scales or broken or lanugo hairs; even the follicles have disappeared, 
 as may be ascertained by painting the surface with tincture of 
 iodin. 
 
 
 wF & 
 
 
 
 
 W m • 
 
 
 nj Ik 
 
 
 
 
 H 
 
 -J 
 
 L •• 
 
 
 
 Fig. 124. — Pseudo-pelade of Brocq. 
 
 This affection is met with on the hairy scalp of youthful or adult 
 individuals, especially in men and rarely in the beard. The medium- 
 sized and large spots are evidently the result of growth and con- 
 fluence of small spots. The onset is insidious and usually escapes 
 notice; Dreuw believes that it takes place in childhood as an alopecia 
 parvimaculata. 
 
 In watching the progress of the affection, which is extremely 
 slow, it is seen to begin with a slight orificial keratosis at one or 
 several hairs surrounded by a pinkish area, at the border of the 
 patch; next follows the definite loss of these hairs and the extension 
 
394 FOLLICULOSES 
 
 of the cicatrix to this area. Despite all efforts and despite the prob- 
 ability of a parasitic cause no special fungus or microbe has ever 
 been found in the hairs or in the follicles. Under the microscope a 
 cellular infiltration is seen around the follicles and around the blood- 
 vessels and lymph vessels which are greatly dilated; the process 
 terminates in a connective-tissue and elastic atrophy. It is certain 
 that pseudo-pelade must be considered as a folliculitis, but it will be 
 noted that the follicular inflammation is clinically not very evident, 
 far less so than in the following forms. 
 
 The differences between pseudo-pelade and ringworm are con- 
 siderable. There is a much greater analogy with the cicatrices of 
 favus, so much so that in my opinion the disease would be better 
 designated pseudo-favic alopecia, but there have never been yellow 
 pits or scutula, the cicatricial skin is not so red, the hairs are not 
 dull and lusterless and there is no fungus. The patches of lupus 
 erythematodes are less numerous and the process extends in the 
 form of very red and hyperkeratotic spots. 
 
 By means of sulphur lotions, sulphur, cade, naphthol, resorcin 
 salves, mercurial ointments, etc., one may hope to arrest the 
 progress of the disease, but not to restore the hairs whose follicles 
 have been destroyed. The treatment should therefore begin as 
 early as possible. 
 
 Folliculitis Decalvans. — Folliculite epilante of Quinquaud — acne 
 decahans of Lallier — is perhaps merely a variety of the preceding 
 type from which it differs only by the presence in the invaded zone 
 of a few scattered pustular follicles, the size of a pinhead or a small 
 pea. 
 
 Lupoid Sycosis of Brocq. — Lupoid acne of American writers, 
 ulerythema sycosiforme of Unna, dermatitis sycosiformis atrophicans 
 of Ducrey and Stanziale, is situated on the beard and especially on 
 the cheeks (Fig. 125). It gives rise to agrainated follicular pustules, 
 with inflammatory redness and diffuse superficial infiltration of the 
 skin. 
 
 It differs from ordinary sycosis by its tendency to extend uni- 
 formly and by the red, smooth, central cicatricial alopecia, often 
 of a keloidal appearance, which it leaves behind. It may greatly 
 resemble a flat lupus vulgaris in course of central cicatrization; 
 but there are no lupomas and only suppurative folliculitis. The 
 single focus, or at most two or three foci, in the course of years may 
 attain the dimensions of the palm of the hand. 
 
 Depilating follicvlitides of the smooth parts, described by Arnozan 
 and Dubreuilh, which occupy the thighs and legs, are still more 
 rare; they constitute a type related to the above or perhaps a form 
 of tuberculides. 
 
 Furthermore, an entire series of cases of necrotic (Janovky) or 
 
SUB A C V TE FOLLIC VLI TI DES 
 
 395 
 
 ulcerative (Bizzozero) jolliculitid.es or perifolliculitides has been 
 reported; their significance and nosological position have not been 
 determined. 
 
 Treatment. — Washes with alcohol or sublimate, yellow oxide 
 salves and mercurial plasters, combined with epilation, have long 
 been the best means for combating the progress of lupoid sycosis 
 and analogous affections. Radiotherapy is greatly superior to 
 these measures and vields note worth v results. 
 
 Fig. 125. — Lupoid sycosis. 
 
 SUBACUTE FOLLICULITIDES. 
 
 There exists a group of red folliculitides, of acute or rather sub- 
 acute course, which are neither regularly suppurative nor necessarily 
 depilatory. 
 
 Follicular Eczematides. — I employ this term for the peripilar 
 seborrheids of authors. The acute form manifests itself especially in 
 markedly kerotic men, preferably at the beginning of the warm 
 weather, in the form of an eruption of small red acuminate follic- 
 ular papules, agminated in one or several patches on the back, the 
 shoulders or the anterior side of the trunk. The patch extends by 
 invasion of all the neighboring follicles, while at the center the 
 eruption subsides and leaves behind a yellow slightly desquamating 
 surface. The course is rapid at the onset. The diseased surface 
 attains the size of the hand in the course of a week or two; later on 
 it is sluggish. 
 
396 
 
 FOLLICULOSES 
 
 A subacute form of this affection has been frequently described. 
 It is characterized by small spots of a yellowish red, or a purplish 
 red, perifollicular, barely papular, arranged in groups of ten to 
 thirty, which gradually become more prominent and covered with 
 a yellowish scale or crust (Fig. 126). Continence of these lesions 
 may lead to the production of spots of figured eczematides. 
 
 Their scat of election is, moreover, the same as that of the figured 
 eczematides which may have preceded the follicular eruption. The 
 latter is frequently seen also on the limbs, the thighs, the legs, the 
 wrists, the forearms, etc. Pruritus is very slight. 
 
 Treatment with sulphur baths, sulphur or ichthyol salves, is very 
 promptly effective in the acute form; it must be more energetic or 
 more prolonged in the sluggish varieties. 
 
 Eczema Folliculorum of Malcolm Morris and Unna is, I believe, 
 merely a rare variety of the preceding affection. It consists of a 
 non-suppurative folliculitis, agminated in small red patches, which 
 are distributed on the trunk and especially on the limbs, progres- 
 sing extensively, with a tendency to complete eczematization. 
 Pruritus is sometimes rather troublesome and causes scratching. 
 This form is somewhat rebellions to treatment. 
 
 Follicular Syphilides. Among the papular secondary syphilides, 
 there is a form with small papules, known as miliary, granular, 
 lichenoid, or acneiform peripilar syphilides. They result from a 
 localization of the syphilitic infiltration around and beneath the pilo- 
 
SUBACUTE FOLLICU LI TIDES 
 
 397 
 
 sebaceous follicles; it usually seems to be invited by a preliminary 
 lesion of these follicles, in the form of kerosis or of keratosis pilaris. 
 The follicular syphilides usually make their appearance from four 
 to eighteen months after the chancre; this is therefore a secondary 
 manifestation but not one of the earliest. A distinction is made 
 between a papulo-squamous, papulo-pustular and even a vesicular 
 
 Fig. 127, 
 
 -Follicular syphilides, papulo-squamous variety. On the face the eruption 
 was distinctly papulo-lenticular. 
 
 variety. The eruption is disseminated but very often consists of 
 small groups of agminated lesions (Fig. 127). Its seat of election is 
 on the trunk, where it is seen on the back, flanks and loins; the 
 limbs may also be involved. 
 
 The papulo-squamous variety consists of small miliary elevations, 
 of a dusky red color, acuminate and crowned with a dry scale 
 
398 FOLLICULOSES 
 
 which is enclosed in the follicular orifice and not easily removed. 
 The principal features of these lesions are their firmness, so that 
 they feel like granules to the finger and their relatively slow devel- 
 opment; they persist several weeks without change. 
 
 The papuh-pustular variety may become combined with the 
 preceding in the same eruption, or it may exist alone; it is often 
 very diffuse and abundant. The dark-red perifollicular protuber- 
 ance is larger than in the squamous variety, even lenticular in size; 
 it is surmounted by a vesico-pustule, always containing much less 
 fluid than one would expect, rapidly drying into a crust. Under 
 the vesicle or the crust is seen a dilated, sometimes eroded follicular 
 orifice. 
 
 According to the size and appearance of the papulo-pustules or 
 papulo-vesicles, the terms of acneiform, varicelliform, herpetiform, 
 varioliform syphilides have been employed (A. Fournier). There 
 occur transitional cases between this variety and the papulo-crusted 
 or ulcerative syphilides. 
 
 Whether squamous or pustular, these syphilides may in some 
 cases become arranged in rings, or grouped in collections of about 
 fifteen to at most fifty lesions, sometimes around a large lenticular 
 or crusted papule. These agminated efflorescences, absolutely char- 
 acteristic of syphilis, have been picturesquely described as syphilides 
 en bouquets and corymbiform syphilides. 
 
 Careful study of the features of the eruption and the concomitant 
 symptoms will guard against confusion of follicular syphilides with 
 keratosis pilaris, follicular eczematides, pityriasis rubra pilaris, or 
 with acne, papulo-necrotic tuberculides, etc. The differential diag- 
 nosis from lichen scrofulosorum may be much more difficult even 
 with the help of a biopsy, for their structure is rather commonly 
 tuberculoid, but there is a positive Wassermann reaction. 
 
 The follicular syphilides are tenacious, rebellious to treatment, 
 often leave persistent brownish macules, and have a tendency to 
 recurrence. Treated with mercury, they last six weeks or longer; by 
 means of arsenobenzol they can be removed in two or three weeks. 
 
 Follicular Tuberculides. — I have previously discussed the lich- 
 enoid tuberculides with small acuminate and peripilar lesions, which 
 belong under the heading of lichen scrofulosorum. 
 
 The papulo-necrotic tuberculides seem to be so evidently related 
 to the follicles that their first description by Barthelemy was given 
 under the names of folliclis and aortitis. Histological examination 
 serves to confirm the clinical impression in this respect. It would, 
 therefore, be justifiable to group them among the folliculoses; at 
 any rate, the question of their differential diagnosis from follicular 
 affections is constantly raised. Their follicular localization is really 
 accidental, however; it is sufficient proof to point out that these 
 
PITYRIASIS RUBRA PILARIS 399 
 
 tuberculides very commonly affect the palmar region, where follicles 
 are absent. The reader is therefore referred to another chapter 
 for this description. 
 
 PITYRIASIS RUBRA PILARIS. 
 
 Devergie, E. Besnier and Richaud have described under this 
 name a skin disease distinct from psoriasis, from genuine pityriasis 
 rubra [Hebra] and from lichen planus, in spite of a few real analogies. 
 On the other hand, Hebra and Kaposi have studied under the name 
 of lichen rubra acuminatus an eruption resembling it to such a 
 degree that at the International Congress, Paris, 1889, the identity 
 of the two pathological types was admitted ; Kaposi himself empha- 
 sized this identity. It is desirable, however, to reserve the name 
 of lichen acuminatus only for the acuminate forms of Wilson's 
 lichen, which are, however, very rare. 
 
 The characteristic lesion of pityriasis rubra pilaris is a small 
 squamous follicular papule. It is of a bright or dull red color, or 
 pinkish, sometimes colorless at first, prominent, of acuminate 
 shape with a conical apex which bears a follicular orifice covered 
 by an adherent, dry, white scale, enclosing one or more often 
 atrophied and shrivelled lanugo hairs. These follicular papules are 
 dry; they are never seen to be vesicular or pustular; their size is 
 that of a pin-head or a millet-seed; they are firm to the touch and 
 as a result of their distribution the skin takes on a granular appear- 
 ance and has the feeling of a grater when scrubbed with the hand. 
 
 Isolated at first, these papules multiply and become agminated 
 later on; the intermediate skin becomes reddened and there follow 
 thickened spots, patches, or surfaces, of all dimensions, of a yellow- 
 ish-pink color, covered with pityriasic or psoriatiform, sometimes 
 granular scales, dotted with horny points or quadrilated and lichen- 
 ized. Their borders are, as a rule, irregular, dentated and sur- 
 rounded by characteristic peripilar papules (Fig. 128). 
 
 The eruption is usually distinctly symmetrical. Its distribution 
 is fairly constant in fully developed cases and presents itself under 
 typical aspects in the affected regions: the scalp, as a pityriasis 
 with abundant white scales; the hairs do not fall out; on the face, 
 no pilary cones are seen, but a diffuse scaly redness, with tension 
 of the skin, even ectropion, or a chalky appearance, with greasy 
 crusts on the eyebrows and in the nasogenial grooves; on the 
 elbows and knees, red patches are observed with thick, adherent, 
 roughened scales, less sharply limited than those of psoriasis. 
 
 The dorsal surface of the phalanges, even more than the last- 
 named regions is a seat of election of pityriasis pilaris; sometimes 
 red papules agglomerated in patches are seen; in other cases only 
 
400 
 
 FOLLICULOSES 
 
 blackish horny cones at the pilary orifices; these lesions are almost 
 pathognomonic. The nails are striated. 
 
 The palmar and plantar regions are of a dusky red color; their 
 horny layer is thickened, dry, fissured at the folds, sometimes des- 
 quamating; the transition into healthy skin is gradual, imperceptible. 
 
 The limbs and often also the trunk, are the seat of more or less 
 grouped, acuminate papules and patches or thick and scaly sur- 
 faces, which may cover large stretches, almost the entire body, 
 although a few localities at least are always exempt. The healthy 
 -pairs are angular and limited by concave curves. 
 
 Fig. 128. -Pityriasis rubi 
 five years; the al 
 
 Anterior surface of the thigh; man aged twenty- 
 
 •alized eruption dated hack three years. 
 
 The patients sometimes complain of itching or heat and usually 
 of a sensation of tension. 
 
 The course of pityriasis rubra pilaris is very variable. At the 
 onset, the palmar and plantar regions, or the elbows and knees, 
 or also the dorsal aspect of the phalanges and the hairy scalp may 
 be alone affected for a period of months or years. So-called abor- 
 tive cases are therefore frequently met with. Sometimes, follicular 
 papules, grouped on the limbs or on the trunk, are the only demon- 
 strable symptom. 
 
 As a rule, the more or les> prolonged periods of invasion and 
 confluence arc interrupted by long stationary stages. Sudden 
 extensions, as in exfoliative erythroderma, are likewise noted. 
 
FOLLICULAR KERATOSIS 401 
 
 The histological lesions consist essentially of a laminated hyper- 
 keratosis of the follicular infundibulum, composed of horny plugs, 
 around a hair which is preserved or atrophied or broken off short. 
 The granular layer persists and is sometimes even hypertrophied. 
 The rete is thinned or slightly thickened, sometimes stretched. 
 The congested papillary body presents a variable degree of cellular 
 infiltration, often rather scanty and diffuse. There is nothing 
 to suggest psoriasis or lichen. 
 
 The nature of the disease is shrouded in mystery. It is known 
 to occur at any age, especially during adolescence and youth, the 
 male sex being somewhat more frequently affected, but its etiology 
 is entirely unknown. 
 
 In December, 1906, Milian suggested a tubercular origin of 
 pityriasis rubra pilaris, on the ground of: (1) The remarkable 
 frequency of tuberculosis among these patients; (2) the existence 
 of intermediate cases between lichen scrofulosorum, true tuber- 
 culides and pityriasis rubra pilaris; (3) the positive tuberculin 
 reaction which is obtained in cases of pityriasis pilaris. But these 
 proofs are not sufficiently convincing. Since that time, some 
 confirmatory cases have been observed and a goodly number of 
 others which do not harmonize with this interpretation. It is 
 therefore still an open question whether or not pityriasis rubra 
 pilaris should be regarded as a perifollicular tuberculide, related 
 to lichen scrofulosorum and akin to the pityriasis rubra of Hebra- 
 -ladassohn. 
 
 The diagnosis is often very easy; in doubtful cases, confusion 
 may possibly occur with other peripilar skin diseases, especially 
 keratosis pilaris rubra and lichen spinulosus, or with the erythro- 
 dermas, with psoriasis and with lichen planus. 
 
 The classical treatment heretofore has been that of psoriasis: 
 baths and soap, with arsenic and tonics internally. In view of the 
 possible tubercular character of pityriasis rubra pilaris, emphasis 
 must be placed on hygienic measures, fresh air, strengthening food, 
 cod-liver oil. Milian was impressed with the remarkable improve- 
 ment produced by injections of tuberculin. I have employed them 
 together with injections of novarsenobenzol and have obtained 
 encouraging but inconstant results. An attempt should also be 
 made with radiotherapy. [I have found the .r-ray entirely useless.] 
 
 FOLLICULAR KERATOSIS. 
 
 In the folliculoses of this kind, the inflammatory character is 
 well-nigh obliterated; some of them may be considered as mal- 
 formations. 
 26 
 
402 FOLLK CLOSES 
 
 Keratosis Pilaris Simplex. — This disease, also known as lichen 
 pilaris (Bazin), cacotrophia folliculorum (T. Fox), ichthyosis anserina 
 scrofulosorum, xeroderma pilaris, is extremely common. Nearly 
 one-third of all individuals of both sexes suffer from it to some 
 degree; it is hereditary in many otherwise healthy families. 
 
 This fact easts a doubt on the relationship of this affection to 
 scrofula; it cannot be simply dismissed as a tuberculide. Its rela- 
 tions with ichthyosis, which practically always accompanies ostio- 
 follicular keratosis, are on the contrary obvious. 
 
 Keratosis pilaris appears toward the age of two or three years, 
 flourishes between fifteen and twenty and subsides at an adult age. 
 Mild cases are the most common. 
 
 It usually occupies the external surface of the arms and thighs, 
 often also the calves, the lower part of the legs, the forearms, elbows 
 and knees, the waist and the hips, sparing fatty and moist regions. 
 
 The symptoms consist of dryness of the skin with roughening due 
 to more or less marked acuminate papular elevations; these are 
 follicular orifices filled with a very adherent grayish horny cone, in 
 which the downy hair is rolled up as a spiral. The color of the 
 integument is sometimes normal; in other cases, of more severe 
 type, the follicular constituents are red or purplish, representing 
 keratosis pilaris rubra. 
 
 In the course of time, the shrivelled hairs disappear, the elevations 
 become flattened and transformed into punctiform cicatrices. 
 
 Although of the nature of deformities of embryonic origin, like 
 the nevi, keratosis pilaris takes a course which leads to total atrophy 
 of the affected follicles and their sebaceous gland and to alopecia 
 of the invaded regions. 
 
 Young girls or young women frequently seek advice on account 
 of the roughened condition and red dots on their arms. The same 
 internal medication is recommended as for ichthyosis. Locally, it 
 is advisable to avoid pumice stone and rubbing with alcohol, but 
 the skin should be kept anointed with a fatty substance, a soapy 
 salve, vaselin, or glycerol of starch containing salicylic acid. From 
 time to time, the skin should be cleansed with green soap; [a salicy- 
 lated eucerin salve is useful]. 
 
 Keratosis Pilaris Rubra Atrophicans of the Face. — This affection, 
 named folliculitis rubra by Wilson, ulerythema ophryogenes by Unna, 
 was studied by Brocq, who pointed out its connection with keratosis 
 pilaris simplex. It is observed in youthful or adult individuals, 
 preferably in males. 
 
 It is situated on the eyebrows, especially at their outer third, 
 on the lower portion of the forehead and in the parotid region; 
 furthermore, it is not infrequently combined with simple keratosis 
 pilaris in the elective territories of the latter. It is characterized 
 
FOLLICULAR KERATOSIS 403 
 
 by a diffuse redness, with a granular surface due to the acuminate 
 elevations of the pilary orifices, from which protrude scanty and 
 deviated hairs. Later on, the affected surfaces become bald and the 
 beard especially grows only very scantily; moreover, fine cicatricial 
 spots are seen, sometimes in an anastomotic network. 
 
 The atrophic tendency is therefore more pronounced than in 
 simple keratosis. Brocq has pointed out the kinship between this 
 keratosis rubra pilaris of the face and moniliform aplasia; the two 
 affections may coexist. 
 
 In pilary keratosis of the face, which is very obstinate, the con- 
 dition may be improved by repeated applications of green soap; 
 red oxide ointment is equally successful. Crossed linear scarifica- 
 tions may be indicated. 
 
 Lichen Spinulosus. — Under this name, first used in England, 
 several skin diseases of unknown and probably different character 
 have been described. Their characteristic symptom consists in the 
 presence of more or less long and dry, filiform horny protuberances 
 emerging from the pilo-sebaceous orifices which are themselves 
 slightly raised and of normal or faintly pink color. 
 
 The lesion is encountered in youthful individuals and occupies 
 diffusely the face, or the neck, or the limbs, or the buttocks (acne 
 cornee of French authors) ; or it may be arranged as circumscribed 
 patches on the trunk and the buttocks (acne keratique of Tenneson) ; 
 or it appears ia little children and covers large surfaces (lichen 
 spinulosus of R. Crocker and Adamson). 
 
 The duration of this dermatosis is variable; several times it has 
 been known to disappear spontaneously in a few weeks or months. 
 In one case I have found large numbers of demodex in the affected 
 follicles. 
 
 Analogous horny protuberances may be observed in lichen scrof ulo- 
 sorum, in the peripilar syphilides, etc. It must therefore be kept in 
 mind that the spinulation is not the pathognomonic sign of a single 
 and always identical affection. 
 
 Ichthyosis Follicularis. — This term and that of keratosis follicu- 
 laris have been employed by various writers to designate actually 
 non-classifiable affections which resemble either psorospermosis fol- 
 licularis but without dyskeratosis, or ostiofollicular hyperkeratotic 
 nevi, etc. A familial and contagious form has been described by 
 Brooke. 
 
 In the differential diagnosis of these various follicular keratoses, 
 it must be remembered that lichen planus may exceptionally assume 
 the form of acuminate papules ; that pityriasis rubra pilaris includes 
 numerous incomplete, entirely localized cases; that spinulation is 
 encountered in several diseases; finally, that the follicular syphilides 
 are sometimes discrete and often very polymorphous. 
 
CHAPTER XX. 
 TRICHOSES. 
 
 The name "trichoses" (0pi£, t P lx6s = hair) is applied to the 
 diseases and anomalies of the hairs on the head and body. 
 
 The hairs are filiform corneal structures whose root is inserted 
 in the pilary follicles; they are a secretory product of the terminal 
 papilla of these follicles which they cover with their enlarged 
 extremity, known as the bulb. This bulb is hollow while the hair 
 is still growing; it closes up and becomes solid when the hair has 
 completed its development and is ready to fall out. When a hair 
 has fallen out or been forcibly removed, unless the deep portion of 
 the follicle has been destroyed, it is replaced as a rule by another 
 hair, which forms in a diverticulum of the original follicle. 
 
 The structure of the hairs is very simple. They consist of more 
 or less pigmented elongated corneal cells, forming what is known as 
 the cortex of the hair; of an external cuticle; and of a central medul- 
 lary canal, which may be absent. 
 
 Under the heading of trichoses belong: (1) the hypertrichoses; 
 (2) the hypotrichoses or alopecias; (3) the dystrophic trichoses; (4) 
 the parasitic diseases of the hairs. 
 
 Obviously, it would be logical to group the majority of the trichoses 
 with the folliculoses. As a matter of fact, a pilary hypcrproduction 
 or an alopecia is the manifestation of a trophic disturbance of the 
 papilla of the hair; in the tineas, the parasites attack simultaneously 
 the root of the hair and its sheaths. But this follicular lesion is not 
 apparent; the striking feature consists in the malformation, fall, 
 absence or alteration of the hairs. In accordance with the plan of 
 this book I shall therefore devote a special chapter to the trichoses. 
 
 HYPERTRICHOSES. 
 
 Hypertrichosis, an anomaly consisting in an overproduction of 
 hairs which are larger, more abundant and more highly pigmented 
 than is appropriate for the affected region or the age and sex of the 
 subject does not always represent the same type of disease. Some- 
 times, it accompanies congenital hyperkeratosis. The pure eases 
 should be grouped, as already indicated by Virchow, into three 
 classes, between which intermediate forms are encountered. 
 
H YPER TRW HOSES 
 
 405 
 
 1. Nevl yilosi are very common, often multiple, small and lentic- 
 ular, or very extensive and may cover large areas (Fig. 129, A) 
 Even when they are not verrucous, the skin is usually pigmented and 
 
 -Three types of hypertrichosis. A, nevi pilosi; B, hypertrichosis fetalis; 
 C, true hypertrichosis of masculine type. 
 
 nevus cells may be found in it. They are as a rule sharply circum- 
 scribed. Their arrangement is not perfectly symmetrical. They 
 may develop after birth. 
 
406 TRtCtiOSES 
 
 2. Hypertrichosis fetalis or lanuginous pseudohypertrwliosts of 
 
 Bonnet —is seen in so-called wild men or human canines and consists 
 in the abnormal persistence of the fetal hairs which, moreover, are 
 hypertrophied. It is symmetrical, increases with age, occupies 
 regions which even in persons with a very strongly developed hairy 
 system are rather smooth, like the forehead and the nose. The 
 hairs are wooly, soft and curly. The affected individuals usually 
 present serious dental anomalies. Yirchow designated this form as 
 hypertrichosis of fin' edentata (Fig. 12!) B). 
 
 3. True hypertrichosis must be considered separately in the two 
 sexes. 
 
 In men it is merely an exaggeration of the normal state which is 
 itself extremely variable. It does not really manifest itself until 
 puberty which may be premature. Together with an abundant 
 hairy growth of the beard and other hairy regions, an almost ape- 
 like hairy proliferation may appear symmetrically on the chest, 
 back and limbs; sometimes the hypertrichosis predominates in 
 the sacral region, forming the tuft which the ancients considered as 
 an attribute of the fauns. 
 
 Masculine hypertrichosis is not uncommonly hereditary or 
 atavistic. It has been observed to occur not infrequently in tuber- 
 culous individuals. 
 
 In women, hypertrichosis of the masculine type constitutes the 
 form which is of chief interest to the dermatologist. 
 
 The patients are usually young girls or young women who have 
 noticed since puberty, first the development of a troublesome downy 
 growth, followed by hypertrophied hairs on the upper lip, the chin, 
 or the cheeks and more rarely by complete beards made up of 
 15 to 20 thousand hairs (Fig. 129, C). In some eases, the chest, the 
 breasts, or the limbs are the seat of this abnormal hairy growth. 
 
 These hypertrichoses of young girls not unfrequently is the 
 occasion of a real pathological obsession, known as trichomania, 
 which plunges them into despair and melancholia, even in cases 
 where the down is hardly disfiguring. 
 
 Much more common is the appearance of large hairs on the chin, 
 or of a moustache in women of thirty to forty years or especially 
 at the time of the menopause. 
 
 The cause of this deformity is sometimes hereditary; a natural 
 tendency is apt to become aggravated by local irritations, the 
 employment of depilatory pastes or of the razor and especially by 
 epilation with the forceps. On the other hand, there undoubtedly 
 exists a possible, but actually very inconstant relation between 
 hypertrichosis of the masculine type and the genital functions. 
 
 This relation is indicated by eases of precocious menstruation and 
 sexual maturity in hypertrichotie individuals on the one hand and 
 
ALOPECIAS 407 
 
 on the other by the hypertrichosis of the menopause. Lesser 
 observed a girl of six years who had menstruated since the age of 
 three, had the breasts of an adult female and was more hairy than 
 a man of thirty years. 
 
 In both sexes, repeated local irritation, scratching, phototherapy, 
 etc., may give rise to regional hypertrichoses. Other cases are of 
 kerotic origin. 
 
 According to observations made in the course of the war, by G. 
 and M. Villaret and others, a hypertrichosis which develops on the 
 cutaneous territory of a traumatized nerve generally coincides with 
 hyperidrosis and with the absence of the reaction of degeneration 
 and indicates an incomplete injury, not a definite lesion of the nerve. 
 Inversely, a hypotrichosis originating under the same conditions is 
 usually accompanied by the reaction of degeneration and indicates 
 a complete interruption of the nerve. 
 
 Treatment. — The question of treatment arises only in cases of 
 hypertrichosis in young girls and women. At the onset, it is especi- 
 ally necessary to forbid all local irritations and especially epilation. 
 
 Too plainly visible downy hairs may be bleached with strong 
 hydrogen peroxide solutions after all fat has been removed, or a 
 peroxide cream may be prescribed. A salve made with thallium 
 acetate (1 per cent.) will cause a large proportion of the hairs in 
 the medicated region to drop out, but has the disadvantage of under- 
 going absorption and thereby acting at the same time on the hairy 
 scalp and the eyebrows. 
 
 When the hairs are really excessively large no recourse is left but 
 electrolytic epilation, which is radical, not particularly painful, 
 leaves hardly visible cicatrices when properly performed but is 
 very tedious when the hairs are at all numerous. For the technic, 
 the reader is referred to special contributions, especially by Brocq, 
 who has carefully investigated this question. 
 
 Radiotherapy is often demanded by these patients, but cannot 
 at present be recommended. 
 
 Outside of the hairy scalp, its epilating action is unreliable and 
 too dangerous to employ; in large doses, it exposes to very unde- 
 sirable pigmentations and incurable spots of radiodermatitis 
 atrophicans developing after a few years. In weak doses, a renewed 
 and sometimes exaggerated growth may be expected after a variable 
 length of time. 
 
 ALOPECIAS. 
 
 The term alopecia {aKccivr]^ = fox) is indiscriminately applied 
 to the fall of scalp or lanugo hairs (defiuvium) , to the resulting 
 hairlessness and even to the congenital absence of hair. 
 
 The congenital alopecias [atrichia] are very rare and often familial ; 
 
408 TRICHOSES 
 
 in their distribution they are diffuse or regional and occasionally 
 
 circumscribed. The piiary agenesia may be pure, or essential; or 
 it may be associated with nevi, congenital hyperkeratosis, keratosis 
 pilaris, monilethrix, more or less pronounced cutaneous atrophy, etc. 
 
 The acquired alopecias are divided into two classes, according to 
 their being diffuse and regional, or on the contrary circumscribed. 
 The hairy scalp is their seat of predilection and, unless otherwise 
 indicated, the following remarks will deal particularly with this 
 region. 
 
 Regional and Diffuse Alopecias. — Traumatic Alopecias. — Certain 
 traumatic alopecias are diffuse. The scalp or body-hairs may have 
 been pulled out, accidentally, with a therapeutic object or for 
 purposes of simulation. The name trichotillomania designates a 
 sort of tic or bad habit which causes some persons incessantly to 
 pull or tear out the hairs of a given region. 
 
 Contusions and wounds give rise only to circumscribed alopecias. 
 But the rubbing of the head on the pillow, especially at the occipital 
 and parietal prominences in some weakly or hydrocephalic children; 
 friction of the vertex in women, caused by combs or coiffures; 
 friction of the clothing on the wrists or legs; scratching in conse- 
 quence of pruritus — all of these induce deterioration and falling of 
 the hairs, a condition which may be grouped under the heading of 
 traumatic alopecia. 
 
 Pathological Alopecias. — These are much more common. It would 
 be logical and may seem easy a priori to subdivide them into two 
 groups, according as the fall of the hairs depends upon a local 
 affection or is the result of a disturbance of the general health, such 
 as an infectious, dyscratic, or cachexia-inducing disease. 
 
 Sometimes the local affection is evident: In this way an eczema 
 of the hairy regions, the exfoliative erythrodermas and very exten- 
 sive tineas, may lead to diffuse alopecia. I shall not dwell on this 
 class of eases, the diagnosis of which is very easy, the treatment 
 being that of the causative disease. 
 
 In other cases the hairy scalp appears healthy; here an investi- 
 gation will disclose the existence of one of the general diseases which 
 will be discussed further on. 
 
 In the vast majority of the cases of diffuse alopecia, however, 
 only mild or ordinary lesions are found on the alopecic skin, such 
 as pityriasis, seborrhea, etc., which one may hesitate to consider as 
 causative. These conditions are interpreted by some writers as 
 accessory and irrelevant, by others as the actual cause of the 
 alopecia, in my opinion, these various pathological phenomena are 
 not interdependent, but are all alike derived from kerosis. 
 
 Kerotic Alopecia and Calvities. — Kerosis is the name which I 
 apply to an extremely frequent cutaneous dystrophy, shown by 
 
ALOPECIAS 409 
 
 combined manifestations such as pityriasis simplex, seborrhea, 
 hyperidrosis and nutritional disturbances of the pilary system, in 
 the form of hypertrichosis or alopecia. In different cases, one or 
 several of these symptoms may predominate. 
 
 It is customary to consider as special pathological types and to 
 describe separately, alopecia with seborrhea {alopecia seborrheica) 
 with pityriasis {alopecia pityrodes, pellicularis,furfuracea) , and the ap- 
 parently essential alopecia {alopecia senilis, prematura and cahities). 
 
 However, these types are very imperfectly defined and can be 
 included in one and the same description, a few words sufficing to 
 point out the different clinical varieties of kerotic alopecia. 
 
 On the scalp, its seat of predilection, kerotic alopecia is diffuse, 
 but regional and progressive. It begins at the vertex, at the place 
 of the tonsure and at the sides of the forehead. As it progresses it 
 becomes generalized and spreads at an extremely variable rate. 
 It may stop half-way or even retrograde slightly in youthful and 
 properly treated individuals. Often, however, it progresses inexor- 
 ably, denuding the entire top of the head ; it spares for a fairly long 
 time a median island at the top of the forehead and almost always 
 definitely the temporal and lower occipital regions, so that a semi- 
 circle of hairs is left passing from one temple to the other across 
 the nape of the neck. 
 
 Before becoming detached, the bulb of the hairs has become solid 
 and they will then yield to the slight traction of the brush, etc.; a 
 few days later they fall out spontaneously. 
 
 The fall may be continuous, or it may occur paroxysmally in 
 variable degrees. Although there are in this respect great individual 
 variations or differences according to age, season of the year, mode 
 of life, etc., a scalp which regularly loses from thirty to forty hairs 
 daily may certainly be said to be in course of denudation and the 
 ratio of the daily fall is often much higher. 
 
 The fallen hairs, which at first are healthy and of normal calibre, 
 are always replaced; but the successive generations are more and 
 more delicate, until they are finally represented merely by a fine 
 down, which may disappear in its turn. The resulting condition is 
 total baldness {cahities hippocratica) . The skin of the scalp becomes 
 white, smooth, glistening, polished, and seems to be atrophied or at 
 least slightly thinned. 
 
 In the course of the development of the disease, the scalp has 
 almost invariably become affected with the oily scales of pityriasis, 
 with seborrhea and hyperidrosis. For a time there may have been 
 a production of scaly crusts or more or less circumscribed and figured 
 surfaces, accompanied by pruritus; as a matter of fact, eczematides 
 are common on the scalp of kerotic individuals and may recur in 
 bald persons who neglect personal cleanliness. 
 
410 TRICBOSMS 
 
 Varieties.- As stated above, the varieties of kerotic alopecia are 
 
 very imperfectly defined. 
 
 According to authors, alopecia seborrheica is said to be precocious 
 
 and rapid in its development, plainly regional and strongly denud- 
 ing; alopecia pityr'odes referring to fatty pityriasis, as the dry pity- 
 riasis is not depilating (Sabouraud) — is said to be more diffuse and 
 always incomplete; alopecia senilis is supposed to depend upon 
 cutaneous atrophy and to be unrelated to seborrhea and pityriasis; 
 it is slowly progressive and the most relentless in its advance; 
 alopecia prematura, often familial, may begin toward the age of 
 twenty years and cause baldness at twenty-five or earlier, but has such 
 variable features that its pathogenesis is by no means agreed upon. 
 
 In women, notably in young girls and young women, an abundant 
 fall of hairs is very common in recurrent, sometimes seasonal periods, 
 with more or less fatty pityriasis ; but it only exceptionally leads to 
 baldness. The latter is seen in aged women and occupies the temples 
 as well as the sinciput. 
 
 Xerotic alopecia of the beard, the moustache, the eyebrows and 
 cilia, is much less common and accompanies as a rule fatty pityriasis 
 or still more frequently the eczematides of these regions; it is incom- 
 plete and always temporary. Bald individuals usually have a fine 
 full beard. 
 
 On the trunk, notably on the chest, kerosis produces on the con- 
 trary a definite loss of hair in many cases, with persistence of a few 
 thick scattered hairs. 
 
 Etiology. — Having previously discussed the etiological factors of 
 kerosis, I may here limit myself to stating that mental overexertion, 
 night work, a poor dietary hygiene and in fact also a poor hygiene 
 of the scalp, dressing the hair brush-fashion, heavy and badly venti- 
 lated skull-caps, etc., seem to predispose to progressive alopecia. 
 
 Very frequently the ordinary causes become combined with some 
 of the pathological conditions discussed in the next section, con- 
 valescence, anemia, dyspepsia, etc., so that the differential diag- 
 nosis between kerotic alopecia and alopecia of general diseases is 
 often extremely difficult and even impossible in combined cases. 
 The prognosis must therefore be guarded. 
 
 | W< >men rarely are bald ; men rarely lose their beards. In fact the 
 same conditions affecting the scalp and the bearded region in a man 
 may cause a complete alopecia of the scalp while scarcely thinning 
 the beard. May we not seek the explanation of the relatively 
 greater resistance of the man's beard and the woman's hair in an 
 underlying biological fact? The beard of the male and the long 
 hair of the female scalp are secondary sex characteristics and as 
 such might be expected to possess a greater inherent resistance to 
 injury than a useless structure like the hair on the male head.] 
 
ALOPECIAS 411 
 
 Treatment. — After having corrected, if practicable, all that is 
 deficient in the hygiene and health of the patient, the kerosis must 
 be treated systematically and for a long time with reducing agents, 
 sulphur preparations, tar and mercurial lotions, etc. Later on, 
 various stimulating lotions may be prescribed. By these means, 
 the trouble is very often successfully checked, or rather the fatal 
 outcome may be delayed. 
 
 In established baldness, I have seen a few cases of patients, who 
 persisting in very prolonged and energetic treatment, acquired a 
 few strong hairs on the denuded surface, but they remain thinly 
 scattered and the result is by no means satisfactory from the 
 esthetic point of view. 
 
 Alopecias of General Diseases. — A large number of acute infectious 
 diseases — typhoid fever, erysipelas, pneumonia, grippe, the eruptive 
 fevers, the erythrodermas, etc. — are followed during convalescence 
 or after a few weeks' delay by a diffuse acute alopecia. The same 
 may result as a sequel of childbirth, severe operations, serious 
 traumatisms, violent emotional disturbances. 
 
 The fall of hairs in these cases may be slightly marked or so 
 abundant that the hair comes out in handfuls and the denudation 
 is practically complete in a few days, constituting the defluvium 
 capillitii of the ancients. The alopecia may also involve the hairs 
 of the body. The present pandemic of influenza has produced an 
 extraordinary number of cases of alopecia. [The defluvium usually 
 develops about two months after convalescence.] 
 
 When the scalp is not pityriasic, it is useless to cut the hairs which 
 are left; some stimulating washes suffice and the hair grows in again 
 as abundantly as before the disease. 
 
 Syphilitic Alopecia. — This condition may be considered to some 
 degree as a peculiar instance of this class. It occurs very commonly 
 from the third to fifteenth month after the infection. Its onset is 
 often insidious. The scalp is not necessarily the seat of eruptions, 
 crusts, etc., but there is often a combination with pityriasis. 
 
 There is sometimes a mere thinning of the hair, sometimes a 
 regional alopecia [alopecia areolata] which is almost pathognomonic, 
 with its incompletely denuded areas oscupying especially the 
 temporal regions and the occiput. [The alopecia which is pathog- 
 nomonic is what may be described as having a "moth-eaten" 
 appearance.] The coexistence of a pigmentary syphilide of the neck 
 is not uncommon. 
 
 This syphilitic alopecia must not be confused with pyodermic 
 alopecia or with the alopecia areata whose patches even when 
 numerous are usually more completely denuded and more sharply 
 outlined. Syphilitic alopecia may also affect the hairs of the body, 
 the beard, the eyebrows and especially the outer end of the eye- 
 
412 TRICHOSES 
 
 brows. The hair always grows again, for "syphilis makes no bald 
 heads" (A. Fournier). 
 
 hi all the infectious alopecias, a paralysis of the pilary papillae 
 is apparently produced under the influence of toxins, comparable 
 to that which affects the matrix of the nails under the same con- 
 ditions; a very large number of hairs at once assume a solid bulb. 
 The condition is therefore a sort of pathological moulting. 
 
 The absorption of thallium salts produces a total alopecia com- 
 parable in every way with the infectious alopecias. 
 
 Chronic diseases, anemia, diabetes, cancer, myxedema, exophthal- 
 mic goitre, mycosis and the leukemias, utero-ovarian diseases or 
 spaying in women, depressing mental diseases, affections of the 
 liver and intestines and still more frequently tuberculosis, give rise 
 to chronic, diffuse, progressive, alopecias which must be traced to 
 their true origin. In leprosy, the hairs of the face in general and 
 those of the body fall out, whereas the hairy scalp escapes. 
 
 Circumscribed Alopecias. — The first point to be settled in deal- 
 ing with a non-congenital circumscribed alopecia is to decide if it is 
 cicatricial or not. 
 
 In a case of cicatricial alopecia, the surface, grain, sheen, color, 
 consistence and sometimes the mobility of the skin are modified; 
 the hair-follicles have entirely disappeared ; atrophic, brittle, downy 
 hairs are never present; when some hairs are left, they are of normal 
 calibre. 
 
 Cicatricial alopecia may result from a wound, a burn, a caustic 
 agent, or it may follow upon favus, patches of lupus erythematodes 
 or scleroderma, ulcerative tertiary syphilides, pseudopelade, acne 
 decalvans, etc. The denudation is permanent. The local exami- 
 nation and clinical history will clearly indicate the origin. 
 
 A non-cicatricial alopecia is primarily suggestive of alopecia 
 areata. In the first place it is necessary to exclude traumatic 
 alopecia or a voluntary epilation, as observed in schools and 
 barracks, also an existing dermatosis, such as eczema, eczematide, 
 impetigo, etc., which are easily recognizable. 
 
 It is noteworthy that impetigo, furuncle and suppurations in 
 general, ordinarily have behind non-cicatricial, distinctly outlined, 
 round alopecic spots, the size of a dime to that of a silver dollar, on 
 which the re-growth of at first downy then normal hairs may be 
 delayed for several months. 
 
 These post-impetiginous alopecias, better named pyodermic alope- 
 cias-, due to a local blasting of the hairy territory by the toxins of 
 the pyococci, are common in children and are often mistaken for 
 alopecia areata. They are characterized by the macule which 
 may be observed in their center and by the clinical data. A stimu- 
 lating lotion suffices for their cure. 
 
ALOPECIAS 413 
 
 Alopecia areata (la pelade) [area celsi] is the most important of 
 the circumscribed alopecia-producing dermatoses. There exists a 
 generalized form, known as alopecia decahans [or totalis]. 
 
 Alopecia areata is characterized by smooth, sharply outlined, 
 round or oval spots or patches of variable dimensions and number, 
 occupying especially the scalp and the beard. These spots appear 
 insidiously, as a rule without any particular sensation. Denudation 
 of hair is rapid, by tufts, within a few days; it may then slowly 
 spread eccentrically, or over a part of the periphery of the 
 spot. 
 
 The fall of the hairs follows upon preceding imperceptible changes ; 
 they fall out with a solid bulb, many have atrophic roots; further- 
 more, broken atrophic, so-called alopecia hairs are found at the 
 periphery of the patch, or even at a distance when it is about to 
 extend. 
 
 These characteristic alopecia hairs, very abundant in some cases 
 (alopecias with fragile hairs, of Besnier), very rare in the beard, are 
 from 2 to 6 mm. long, pointed like a [wet] brush at the ends, black 
 halfway or in the distal two-thirds, very thin, tapering and decolor- 
 ized toward the root, which terminates in a slight swelling; they are 
 accordingly club-shaped or like a note of exclamation. Being very 
 superficially inserted, they are very easily pulled out with forceps, 
 never breaking off. 
 
 Fresh patches are often rose-colored, slightly edematous, riddled 
 with dilated pilary orifices containing seborrheic utricles (Sabou- 
 raud). After some time, the spot becomes depressed, ivory white, 
 entirely smooth, soft to the touch and easily folded. This stage was 
 called achromatous alopecia by Bazin. 
 
 A healing patch becomes covered with downy hairs which at first 
 are thin, pale and very loosely implanted; these are replaced by 
 stronger downy hairs and finally by normal hairs, actually thicker 
 and darker than the original, but sometimes on the contrary white. 
 The new growth may be central and centrifugal, or it may be 
 centripetal. 
 
 The areas of alopecia, very variable in number, are situated at 
 any point of the scalp, perhaps more frequently near the vertex, 
 on the parietal and the occiput; anywhere in the beard, especially 
 on the sides of. the chin; more rarely on the eyebrows and lids, as 
 well as on other hairy regions of the body. A symmetrical tendency 
 has been noted in some cases and on the other hand a regional dis- 
 tribution in others. 
 
 As varieties may be described : a form with multiple small spots, 
 resembling syphilitic alopecia; a form with a large patch extending 
 like a crown from the nape of the neck, above the temples and to 
 the forehead; this is the ophiasis of Celsus or alopecia coronarius 
 
I I I TRIC HOSES 
 
 peculiar to children, according to Sabouraud; it is especially obsti- 
 nate as are all the alopecias which affect the border of the scalp. 
 
 Alopecia decahans is the most serious variety. It begins like the 
 ordinary form often in very extensive areas which remain limited 
 for several days or even several months. Suddenly, in a few days, 
 the alopecia then becomes generalized over the entire or nearly the 
 entire scalp, face and body, sometimes leaving a tiny tuft or a few 
 islands of hair. In this last named form are sometimes seen a 
 relaxation of the skin permitting it to be easily folded, i. e., hypo- 
 tonia; and lesions of the nails, which will be discussed elsewhere. 
 Slight sensory disturbances have been noted on the smooth surfaces, 
 cryesthesia, hypoesthesias, etc. 
 
 The course of alopecia areata is very variable. Mild cases are 
 cured in two to six months. Recurrences, appearance of new 
 patches before the first have healed and relapses at any time are 
 extremely common. There occur cases of incessant renewal and 
 fall. Alopecia decahans lasts from one to four years and is entirely 
 cured in youthful individuals, incompletely in older patients. 
 
 Etiology and Nature. — Twenty years ago, alopecia areata was 
 almost universally believed to be parasitic and contagious; at least 
 a contagious form was admitted. The stories of epidemics in schools 
 and barracks, quoted in support of this contention, were scattered 
 and blown away like smoke as soon as it could be recognized by 
 careful investigation that there was always a coincidence of sporadic 
 cases with cicatrices and various pseudo-alopecias or with ring- 
 worm. Credit is due to Lucien Jacquet for his indefatigable work 
 in proving the non-contagiosity of pelade; his thousands of experi- 
 mental inoculations on himself and on already affected, therefore 
 predisposed, subjects, did not yield a single positive result. 
 
 In favor of a nervous origin of alopecia areata have been quoted 
 the experiments of Max Joseph who through division of the occipital 
 nerves in cats produced bald spots which, as a matter of fact, had 
 only an apparent analogy with alopecia areata; and on the other 
 hand, the not uncommon coincidence of alopecia areata with 
 neuralgias, headaches and an "unbalanced" nervous state. 
 
 In the dystrophic theory of Jacquet, the predisposing role was 
 attributed either to a complex organic deterioration, as indicated 
 by urinary analysis, or to hereditary factors. On the soil thus 
 prepared, the alopecia was assumed to be elicited and focussed 
 through local peripheral, or visceral, or central irritations. Among 
 the irritations starting the reflex, those of dental origin are the most 
 common; very often the eruption of the teeth, more particularly 
 the wisdom teeth, or dental caries, alveolar inflammations, badly 
 fitting dentures and so forth can be held responsible. There is 
 even a certain relation between the localization of the bald areas 
 and that of the irritative focus. 
 
ALOPECIAS 415 
 
 Taking up the question ab ovo, Sabouraud and his school started 
 of recent years a new inquiry concerning the etiology of pelade. It 
 appears that this affection is hereditary or familial in at least 22 
 per cent, of the cases; the affection is only half as frequent in the 
 female as in the male sex; its maximal frequency of onset is, in both 
 sexes, between the age of six and twelve years; it is furthermore 
 observed with relative frequency in women at the time of the 
 menopause or after a prolonged suppression of menstruation, 
 through spaying, for example, and more rarely in the course of 
 pregnancy. 
 
 Statistics finally show a connection between alopecia areata and 
 thyroid disturbances, especially exophthalmic goitre, where it is 
 apt to be chronic and severe. As to the etiological relations with 
 acquired or congenital syphilis, these are neither clear nor direct; 
 syphilis could be demonstrated in only about 10 per cent, of the 
 cases of alopecia areata. 
 
 These data are undoubtedly interesting, but on the whole it 
 must be admitted that the real nature of alopecia areata still 
 remains unknown. 
 
 Treatment. — Since it is known that alopecia areata is never and in 
 no degree contagious, the prophylaxis of this affection has assumed 
 an altogether different direction. There is now no reason to isolate 
 the patients or to keep them away from gatherings, schools, work- 
 shops, barracks, etc., to refuse them a clean bill of health, nor to 
 suspect hairdressers or barbers, caps, hats, pillows, etc., of having 
 transmitted a disease which is non- transmissible. 
 
 The treatment of alopecia areata and the prophylaxis of relapses 
 or recurrences, are therefore purely individual. 
 
 An effort must be made in a given case to determine the existing 
 factors of nervous and trophic loss of balance, in order to treat its 
 general and deep causes. In the presence of overstrain, bad hygienic 
 conditions, organic or functional disturbances, it may be necessary 
 to recommend relative rest, life in the open air, in the country or the 
 mountains; dry or alcoholic friction of the entire body; hydro- 
 therapy in its tonic or sedative forms, or perhaps various opothera- 
 peutic measures, or the reconstructives, phosphates, arsenic, etc. 
 
 On the other hand it is very important to look for the localizing 
 causes, as it were. A bad condition of the teeth and gums requires 
 attention, even in the absence of pain, congestion, neuralgia, etc. 
 This point must be emphasized ; I have personally seen, like Jacquet, 
 a considerable number of cases which had resisted all local medica- 
 tion heal of their own accord with suggestive rapidity after expert 
 treatment at the hands of a dentist. Sometimes the "peladogenic" 
 focus is to be found in the ears, nose or pharynx and one must 
 proceed accordingly. 
 
416 TRICHOSES 
 
 The local measure* may he summarized as follows: repeated, 
 sufficiently energetic but not exaggerated stimulation of the denuded 
 areas. This stimulation may be mechanical, being obtained by 
 massage, petrissage, brushing, twice daily or oftener; in the stage 
 of re-growth, it must be remembered that of all stimulants epilation 
 acts the most directly upon the pilary papillae. Chemical stimu- 
 lation may be accomplished by means of iodized, acetic or ammoni- 
 acal, chloroform or alcoholic, or other mixtures selected from the list 
 of stimulating and rubefacient lotions; the applications should be 
 made every day or at longer intervals. [Pure liquified phenol 
 allowed to act till the surface begins to whiten, then de-ionized by 
 means of alcohol, applied once in two or three weeks, is an excellent 
 local stimulant.] Vesication or blistering, more particularly by 
 means of a liquid vesicant painted on with a brush, may serve to 
 whip up the pilary growths, as it were. Physical stimulants may 
 also be employed, such as faradization, high frequency currents, etc. 
 I have witnessed in my laboratory, in cases of alopecia decalvans, a 
 remarkable re-growth under the influence of radiotherapy, strictly 
 limited to the stimulated regions; of course the .r-rays must be 
 employed in lower dosages than those which cause epilation (2 to 3 
 units H every fifteen or twenty days). Numerous authors have 
 recently recommended the employment of ultra-violet rays. 
 
 Salves and plasters which are sometimes given to these patients 
 possess no special virtues. 
 
 The condition of the scalp should be attended to as a whole, treat- 
 ing pityriasis, seborrhea, or concomitant lesions if present. 
 
 In order to facilitate the local treatment in cases with extensive 
 or numerous areas, it is advisable to cut off or shave the remaining 
 hair.- In this case a wig will have to be worn, if the patient desires 
 to conceal his condition. When the patches are not very extensive, 
 they can be hidden more or less effectually by touching them up 
 with burned cork. 
 
 DYSTROPHIC TRICHOSES. 
 
 Leukotrichia and Canities. — Congenital absence of pigment in 
 the hairs is known as leukotrichia. It is generalized and accom- 
 panied by a lanugo-like atrophy in albinism, which is very rare, or 
 it may be partial, limited to a tuft of hair, as occurs hereditarily in 
 certain families. 
 
 Canities is an acquired achromia; the hairs on the scalp and body 
 turn grayish, then gray and finally entirely white. It is 'physiological 
 aficr a certain age, but very variable according to races, families, 
 individuals and mode of life; so that in a given case it can be desig- 
 nated as senile or as premature. Its distribution and relative develop- 
 ment on the scalp, the beard and the other hairy regions are so vari- 
 
DYSTROPHIC TRW HOSES 417 
 
 able that no summary account is possible and all that can be said is 
 that the condition is essentially diffuse and progressive. 
 
 Pathological canities, more or less extensive and diffuse, is seen in 
 the course of several nervous diseases and of cachexia. 
 
 Numerous cases have been quoted in which canities is said to 
 have developed suddenly, in a single night, for instance, under the 
 influence of extreme terror; Dr. Parry is said to have seen the hairs 
 of a sepoy who had been tied to the muzzle of a cannon whiten in 
 half an hour. This is highly improbable. I do not know of any 
 observation on sudden canities in the course of the last four years, 
 which have certainly been prolific of unspeakable horrors. 
 
 Sometimes, a partial canities which may be temporary, follows 
 after baldness due to alopecia areata, erysipelas, and so forth. 
 
 The mechanism of the decoloration is unknown. The hairs very 
 rarely whiten, gradually beginning at the root or at the free end. 
 Cases of ringed canities [pili annulati] have been reported, with 
 alternately white and colored segments. As a rule, the blanching 
 is total, progressive and more or less rapid for a given hair. 
 
 The penetration of air between the cells of the hairs does not 
 sufficiently explain the whiteness; there is not only failure of pro- 
 duction but actual destruction of the pigment, either through special 
 pigmentophagous phagocytes, as claimed by Metchnikoff, or more 
 probably through consumption of the pigment in situ. 
 
 The treatment of canities is practically illusory. The role of 
 internal medication and hygiene is limited to raising the general 
 nutritional standard. Stimulating applications, heating the scalp 
 according to some, or epilation of the first white hairs may at the 
 onset delay the appearance of canities. 
 
 Actually, the only corrective agent which certain individuals are 
 obliged to employ for business reasons, consists in the use of hair- 
 dyes. With the exception of burned cork, or henna which gives a 
 red or blond color or a brownish tint, according to its mode of 
 application and hydrogen peroxide which reddens and bleaches the 
 still pigmented hairs, all dyes may be injurious; several are positively 
 dangerous, more particularly those containing paraphenylendiamin. 
 The least harmful are perhaps the silver nitrate and pyrogallic acid 
 preparations. Numerous formulas may be found in special works 
 on this subject. 
 
 Trichorrhexis Nodosa. — Under this name is designated a very 
 common affection of the beard in men and of the scalp and pubic 
 hairs in women, characterized by a localized splitting of the hair, 
 the fibers becoming separated in the form of two brooms pushed 
 into each other. 
 
 This results in the appearance of white nodosities, at the level of 
 which the hair bends and is easily broken off. These thickenings are 
 27 
 
418 
 
 TRICHOSES 
 
 numerous, especially toward the free end and lead to shortening of 
 the scalp or body hairs. 
 
 This affection was considered for a long time as parasitic and 
 contagious. Sabouraud, who found it in nearly all the old shaving 
 brushes examined by him, showed it to be traumatic and due to an 
 excessive withdrawal of oil through abuse of soapy washes and 
 lotions. The remedy is therefore to cut the hairs below the fractures 
 and to keep them constantly oiled. 
 
 Trichoptilosis. — Trichoptilosis is a cleavage in the longitudinal 
 direction of the hairs on the scalp or of long beard-hairs, which 
 become forked at their extremity. Severe chronic diseases or con- 
 stitutional weakness may perhaps act as predisposing factors 
 although it is also observed in perfectly healthy individuals. The 
 disease seems to depend upon an exaggerated dryness of the hair. 
 The treatment is that of trichorrhexis. 
 
 Fig. 130. — Monilethrix, showing the scalp and the parotid and palpebral regions in a 
 child aged nine years. 
 
 Monilethrix or Aplasia Moniliformis. This is a rare, familial 
 and hereditary congenital dystrophy, related to keratosis pilaris and 
 ichthyosis (Fig. L30). 
 
 It consists of a peculiar conformation of the hairs which are alter- 
 nately and regularly constricted and swollen, spindle-shaped, dry, 
 shrivelled, brittle and usually very short: the fractures occur at the 
 
PARASITIC TRIC HOSES 
 
 419 
 
 level of the constrictions; the thicker portions are more pigmented 
 (Fig. 131). 
 
 One is inclined to admit that the formative hair-papilla under- 
 goes changes of dilatation and atrophy, comparable to a pluri- 
 diurnal rhythmic pulsation. The follicles usually present the lesions 
 of keratosis pilaris and often form an acuminate elevation which 
 may ultimately become replaced by a minute cicatrix. The scalp 
 is especially affected and generally appears entirely denuded. 
 Hallopeau showed that the pilary system of the entire body may 
 be involved. Sometimes this dystrophy slightly subsides with 
 advancing age. 
 
 The treatment is that of keratosis pilaris. 
 
 Fig. 131.— Monilethrix. 
 
 PARASITIC TRICHOSES. 
 
 There are two kinds of parasitic diseases of the scalp- and body- 
 hairs: (1) the tineas, in which the parasites reach the hair at its root 
 and invade the follicle as well as the surface-epidermis; (2) the 
 trichomycosis, in which only the shaft of the hairs is affected. 
 
 Tineas. — The name of tineas must be reserved at the present 
 day for a group of parasitic dermatoses of the hairy scalp due to 
 fungi. They are extremely interesting not only for dermatologists 
 
420 TRICHOSES 
 
 but for all physicians, representing very insidious diseases, some- 
 times hard to recognize, of proverbial tenacity, difficult to treat 
 and, moreover, highly contagious. They have, accordingly, a social 
 importance. 
 
 The tineas are three in number: Tinea favosa (favus), tinea 
 microsporica and tinea trichophytica. The last two may be com- 
 bined under the name of tinea tonsurans. The general discussion of 
 their parasites will be found in the chapter on parasitic dermatoses 
 (Chapter XXV). 
 
 Children alone are liable to contract tineas, the reason for this 
 privilege being unknown; it must be assumed that in them the 
 chemical constitution of the scalp differs from what it will be after 
 puberty. Aside from the matter of age, there exist no conditions 
 of immunity. All tineas result from contagion, either direct by 
 contact or more generally indirect by mediation of toilet articles, 
 combs, brushes, clippers, scissors, towels, hats, etc. Transmission 
 between children of the same family is extremely common. Real 
 epidemics may be observed in schools or gatherings of children 
 where an unrecognized tinea-carrier has been admitted. 
 
 With these remarks on the general etiology, each tinea will now 
 be discussed separately. 
 
 Tinea Favosa [Favus]. — The hairy scalp is the seat of predilection 
 of favus. At the onset, the achorion vegetates on the surface, only 
 in the horny layer, where it causes red and scaly spots; this stage 
 usually passes undetected. 
 
 In the fully developed stage, the most typical clinical form is that 
 known as favus scutularis, the "favus a godets" (favus with cups); 
 it is described as favus urceolaris when the scutula are discrete, 
 regular, centered by a hair and of a bright sulphur-yellow color; 
 favus squarrosus, when they are confluent, misshapen and con- 
 glomerated in grayish, powdery, scaly crusts held together by 
 dried pus. 
 
 The spots or patches of favus are of very variable extent, some- 
 times larger than the palm of the hand. The entire scalp may be 
 invaded except a border about 1 cm. in width which curiously 
 enough always remains free. 
 
 On removing the cups (p. 51G) with a curette, there is found below 
 either a smooth depression or a suppurating ulcer or at any rate a 
 subacute dermic inflammation with a tendency to cicatrization. In 
 long-standing patches of favus, cups and crusts are accordingly seen 
 intermingled with smooth, pinkish cicatrices of irregular shape. 
 
 On the favus patches the hairs have in part disappeared; those 
 which persist emerge in tufts from the interstices of the crusts. They 
 are dull, discolored, resembling tow. They do not break easily but 
 yield readily to traction, with their root surrounded by its swollen, 
 
PARASITIC TRICHOSES 42] 
 
 inoist, white or hyaline epithelial sheath. The microscope readily 
 reveals the mycelium in the hairs at least in the first portion of their 
 length. 
 
 The hairs which have fallen out are not replaced. Favus of the 
 scalp leads more or less rapidly to cicatricial alopecia, arranged in 
 spots or networks, characterized by its smooth, shining, more or less 
 reddened and sharply outlined surface; here and there, crinkled 
 hairs of normal thickness and length persist isolated or in small 
 groups. 
 
 In other cases the cups are not apparent and it is the dull and 
 grayish appearance of the hairs emerging from the affected regions 
 which indicates the condition present. 
 
 The pityriasic form of favus manifests itself as distinctly outlined 
 spots, covered with dry gray scales; the microscopic examination of 
 the scanty and lustreless hairs establishes the differential diagnosis 
 from psoriasis or eczema. 
 
 In the impetiginous form of favus, crusts especially are seen, 
 gluing the hairs together and affording a lodging for pediculi. There 
 is always a history of the lesion dating back several years. 
 
 Removal of the crusts exposes a pinkish bald surface ; after some 
 time, scutula appear, pierced by lustreless hairs infiltrated with 
 mycelium. 
 
 The alopecic form very closely suggests pseudo-favic alopecia. 
 There are no crusts or scales, but spots or islands of cicatricial 
 alopecia; at their circumference are seen slightly papular folli- 
 culitides; a microscopic examination of the emerging hairs is neces- 
 sary to establish the differential diagnosis from acne decalvans. 
 
 Tinea Microsporica. — Tinea tonsurans with small spores — or tinea 
 of Gruby-Sabouraud — is frequent in children from four to ten 
 years, especially in boys; it is extremely contagious. When left 
 untreated, it disappears spontaneously at about the age of fifteen 
 years. 
 
 It may be recognized from a distance as round or oval, large or 
 medium-sized, distinctly outlined patches of a dusty appearance, 
 covered with gray foliated scales, whence emerge only a few healthy 
 hairs nearly all being broken off short, of a length of about 3 to 5 
 mm., lustreless and of an ashen gray color, all inclined in the same 
 direction (Fig. 132). 
 
 It is seldom that only a single patch is present; generally from 
 four to ten can be counted. 
 
 The most recent patches are lenticular or nummular in size; the 
 oldest may measure 5 to 6 cm. in diameter or more. The condition 
 has therefore been described as having large patches but small 
 spores. Diseased hairs scattered outside of the patches can never 
 be demonstrated. But the hairy scalp may be involved as a whole. 
 
!_'•_' 
 
 TRICHOSES 
 
 ( )n grasping the hairs of a patch of microsporia tinea between the 
 nails of the thumb and index finger, or between the blades of a pair 
 of forceps, a certain number can be easily pulled out without pain, 
 for they break oil' a short distance below the epidermic surface. 
 
 Viewed with a lens these hairs are seen to be surrounded by a 
 dull white sheath for a distance of 1 or ."» nun. Microscopical 
 examination, after the action of 40 per cent, caustic potash solu- 
 tion, shows this sheath to be formed by a thick and regular layer of 
 round or polyhedral, somewhat uneven spores, measuring from 
 
 132. — Tinea tonsurans m 
 
 jrosporica. The cultures yielded niicrosporon 
 lanosum. 
 
 2 to 4 ji in diameter; the hair thus resembles a rod dipped in glue 
 and then rolled in fine sand. The spores do not generally seem 
 to be accompanied by mycelic threads, are not arranged in short 
 chains and are evidently ectothrix [outside the hair-shaft] (Fig. L33). 
 
 Careful inspection of the hair after it has been freed from its 
 sheath of niosaie-likc spores, may nevertheless reveal delicate 
 mycelic filaments, with widely separated septa, dividing from above 
 downward dichotonously, with superficially emerging brandies, 
 which perhaps give rise to the spores. At the lower portion of the 
 microsporic hair broken off near its bulb, numerous mycelic threads 
 can sometimes be seen, constituting what is known as "Adamson's 
 fringe." 
 
 The presence of friable hairs clinically differentiates the small- 
 
PARASITIC TRICHOSES 
 
 423 
 
 Fig. 133.— Radicular portion of a hair in tinea microsporica (microsporon lanosum.) 
 B and C, microsporon sheath; at A the subjacent threads of mycelium are shown; 
 D, mycelic fringe of Adamson; E, epidermic cells of the cuticle or of the follicle. After 
 Sabouraud. X 260. 
 
424 TRICHOSES 
 
 spored tinea tonsurans from pityriasis capitis, which moreover is 
 generally diffuse; from psoriasis of the seal]) and from the form of 
 dry eczema named tinea amiantacea by Alibert. In these various 
 affections, on the contrary, the length of the hairs is preserved, they 
 are solid and fall out as a whole without breaking. The differences 
 between the small-spored tinea tonsurans and trichophytosis of the 
 hairy seal]) will appear from the following: 
 
 Tinea Trichophytic a. — Trichophytic tinea tonsurans — or tinea 
 with large spores — likewise affects children exclusively; but it may 
 be prolonged until about the twentieth year or exceptionally 
 later. It is actually twice as common in Paris as the small-spored 
 tinea, especially among girls. In contradistinction to the latter, it 
 manifests itself as small patches, scattered in large numbers, or 
 rather as numerous dots, each made up of a few diseased hairs; 
 these dots become fused and may form larger patches, of any shape, 
 but a large number of healthy hairs which hide the diseased hairs 
 usually persist. This tinea has therefore much less striking symp- 
 toms and may escape an inexperienced observer. 
 
 A distinction must be made between two principal varieties, two 
 clinical types, depending upon different trichophytic species. Their 
 distinctive features are as follows, according to the description of 
 Sabouraud : 
 
 1. The diseased hairs, intermingled with numerous healthy long 
 hairs, may be gray, broken off at a height of 2 to 4 mm., bent in all 
 directions, bristling as it were; the epidermic surface is covered w T ith 
 dry or greasy, rather thick scales, containing twisted infected hairs ; 
 this form constitutes trichophyton with crateriform growth [in cultures; 
 briefly T. erateriforme]. 
 
 2. In the other variety, the diseased patches between the surviving 
 hairs are dotted with black points resembling powder grains and 
 sometimes with follicular elevations analogous to those of keratosis 
 pilaris; no diseased hairs protrude; they are enclosed in the horny 
 layer, broken off flush with the surface or twisted on themselves in 
 the follicular ostium. These are cases of trichophyton with acuminate 
 growth [T. acuminatum]. 
 
 The hairs for microscopic examination must not be taken hap- 
 hazard or pulled out with the fingers, for the tinea w r ould then 
 remain unrecognized. Remnants of hairs must be looked for and 
 extracted with fine pincers or with a needle. These diseased hairs 
 will be found to be packed with spores larger than those of micro- 
 sporon and lodged in the substance of the hair itself; these tricho- 
 phytons therefore are endothrix (Fig. 134). 
 
 If the spores are square, lie in tiers or bands with resistant [co- 
 herent] mycelium, the case is one of trichophyton erateriforme. If 
 the spores are rounded or oval, easily separated, the myecelium 
 
PARASITIC TRICHOSES 
 
 425 
 
 brittle and the hair resembles a bag of nuts, the case is one of 
 trichophyton acuminatum. 
 
 According to the investigations of Sabouraud (1908), this micro- 
 scopical difference is not absolute, however, and cultures are required 
 for the differentiation of the two species. 
 
 Tinea trichophytica is more often overlooked than confused with 
 other affections. Not infrequently it is a patch of herpes circinatvs 
 occurring [on the glabrous surface] on the little patient or some one 
 in his invironment that first attracts attention; or there may be a 
 diffuse alopecia accompanied by a slight scaling on the scalp. 
 
 Fig. 134. — Hair in trichophytic tinea, trichophyton crateriformis. Threads composed 
 of quadrangular segments forming bands of mycelium. After Sabouraud. X 260. 
 
 Every pityriasis with multiple spots and all dry eczemas localized 
 on the scalp of children, require a minute and painstaking search 
 for hairs broken off or enclosed in the epidermis and such will very 
 often be found provided one knows how to look for them. 
 
 It is superfluous to emphasize that the broken hairs of alopecia 
 areata which are dry, clubbed, thinned at their base and can be 
 extracted without breaking, in no way resemble the hairs in tinea. 
 
426 TRICHOSES 
 
 Treatment of the Tineas. — No general treatment is required, but 
 these patients recover more promptly when their general condition 
 is improved and when they are placed under excellent hygienic 
 conditions, in the country, at the seaside, etc. 
 
 The prophylaxis necessitates immediate strict isolation of the 
 patient, especially from other children. 
 
 Favus-carriers are dangerous for everybody; children suffering 
 from the microsporic and trichophytic forms can transmit to adults 
 only a readily curable herpes circinatns. All tinea patients, even 
 when collected in a special school reserved for them, like the school 
 of the St. Louis Hospital in Paris, must keep the head constantly 
 covered and be regularly cared for. 
 
 In treating a case of tinea, it is indispensable to begin by cutting 
 the hair short with scissors, repeating this every eight or ten days. 
 The next indications are to outline all the diseased points, to remove 
 or destroy the parasites by appropriate measures and to preserve 
 the healthy portions. 
 
 In a case of tinea tonsurans, after the scalp has been washed with 
 soap, it is advantageous to paint it all over with tincture of iodin 
 diluted with three parts of alcohol; this serves to bring out the 
 affected regions and protects the healthy parts from auto-infection. 
 These soapy washes and iodin applications may be repeated every 
 day or every other day. 
 
 Where a radiotherapeutic apparatus is available, epilation by the 
 .r-rays which evacuates the entire contents of the follicles is the 
 method of choice. As shown by Sabouraud, tineas are curable in a 
 relatively short time by this method — from four to six months, for 
 example, instead of two or three years consumed in the old methods. 
 All the spots are successively exposed to the rays, administering the 
 necessary doses, namely 5 units H. in one session. When the spots 
 are very numerous and scattered, it is necessary to treat the entire 
 seal]), which requires twelve applications, in one or two days. Great 
 care must be taken in outlining the exposed territories, so that no 
 strip of skin either escapes or receives a double dose. The employ- 
 ment of the method therefore requires a perfect apparatus, wide 
 experience and great care. Between the fifteenth and twentieth day, 
 all the hairs together w r ith their roots are cast off; by the thirtieth 
 day, neither hairs nor parasites are left and the child is no longer 
 contagious. The re-growth of hair begins at the end of two and a 
 half months and is complete five months after the session; it goes 
 without saying that during this period the children must be care- 
 fully watched. [It is advisable to paint the scalp with the dilute 
 tincture of iodin once a week for several weeks after the raying.] 
 
 When radiotherapy is not available, a strip 8 mm. in width 
 must be epilated with forceps around each patch, in order to estab- 
 
PARASITIC TR1CH0SES 427 
 
 lish a safety zone; and then, as well as possible, the patches them- 
 selves, where the hairs are unfortunately brittle; these epilations 
 to be repeated every ten or fifteen days. Furthermore the spots 
 should be painted every day with iodin tincture diluted to one-fourth 
 strength; they should be dressed with iodized vaselin or with a 
 chrysarobin salve; occlusion should be maintained by means of 
 zinc gelatin or strips of adhesive plaster. It has also been recom- 
 mended to rub the spots every fifteen days with a pencil of croton 
 oil contained in cocoa-butter. The last named topical agent gives 
 rise to folliculitis with expulsion of the infected hairs, but is liable 
 to leave cicatrices; its action must be closely watched and the 
 inflammation quieted with moist dressings. The treatment is con- 
 tinued in this way until a cure seems to have been accomplished. 
 
 Without radiotherapy, a properly treated small-spore tinea 
 tonsurans lasts about eighteen months; many cases are prolonged 
 for two or four years. This tinea finally always gets well without 
 cicatrices, unless these have been caused by the treatment. 
 
 The prognosis of trichophytic tinea is aggravated by the multi- 
 plicity of the affected points and the difficulty of discovering them ; 
 moreover, it does not disappear spontaneously until the age of 
 eighteen to twenty years. By means of correct treatment, a cure 
 can be obtained in less than one year. It often happens, especially 
 in the trichophytoses, that two or three follicles resist almost indefi- 
 nitely; one is justified in destroying these by electrolysis, by the 
 thermocautery, or by the application of a small droplet of croton 
 oil, introduced with a needle. Many microscopical examinations, 
 repeated every month and yielding negative results, are necessary 
 before the case can be pronouncd cured. 
 
 In tinea favosa the treatment begins with the removal of the 
 crusts and cups by means of moist dressings, salicylated vaselin, 
 or the wearing of a rubber cap, together with frequent shampooing. 
 When the scalp is clean, epilation is performed either by means of 
 the ar-rays or with forceps, which is more efficient in these cases; 
 this is repeated every month. In the interval, the parts are painted 
 daily with dilute iodin tincture or carbolized glycerin. Various 
 ointments of sulphur, copper sulphate, mercurial salts, etc., have 
 also been recommended, but are of no advantage. 
 
 The treatment of favus by epilation, formulated by Bazin, requires 
 at least six or eight months, sometimes over a year. A cure can be 
 considered as probable only after no cup and no infected hair has 
 reappeared for three months after the last epilation. As a recur- 
 rence is even then not excluded, it is necessary to watch the patient 
 during at least another six months. 
 
I-JS 
 
 TRICHOSKS 
 
 TRICHOMYCOSES. 
 
 These are parasitical affections of the hairs, affecting their free 
 shaft, hut not the root or the follicle. Several varieties are known: 
 
 Trichomycosis Vulgaris (Lepothrix of Wilson, or Trichomycosis 
 PalmeUina (Pick) is common in all countries, in the axillary and 
 genital regions, in persons who neglect the demands of cleanliness. 
 The hairs become dull, roughened, nodular, assume a yellowish or 
 reddish color, but are not brittle; there is often a regional hyper- 
 idrosis and ehromidrosis. 
 
 Fig. 135. — Trichomycosis vulgaris; axillary hairs under the microscope. 
 
 Under the microscope, very adherent granular concretions are 
 seen on the hairs, forming an irregular sheath, a sort of rugous 
 cortex (Fig. 135) or nodules at intervals. They consist of zooglea 
 of cocci, attached to erosions of the cuticle of the hairs and agglom- 
 erated in a very hard layer. Colombini successfully cultivated and 
 inoculated this parasite. 
 
 There exist tropical varieties, such as that studied in Ceylon by 
 Castellani (1912), due to Nocardia tenuis. 
 
 Washing with soap and antiseptic lotions or ointments suffices for 
 the treatment; shaving of the hairs is only exceptionally required. 
 
 Piedra ( Trichosporosis Nodularis Tropicalis) gives rise to nodes 
 in the hairs, sometimes of the beard, arranged without order and 
 conveying a sensation of roughness on touch. The rounded or 
 spindle-shaped nodules, sometimes of the form of a unilateral shell, 
 
PARASITIC TRICHOSES 
 
 429 
 
 are whitish, extremely hard and adherent (Fig. 136); they do not 
 make the hairs brittle; Juhel-Renoy counted 23 on a single hair 
 60 cm. in length. 
 
 Fig. 136.- — Piedra nodules completely or partially surrounding the hair. 
 
 They are composed of fairly large spores, belonging to one or 
 various species of trichosporum, heaped up and agglutinated under 
 the cuticle of the hair. This affection is observed in South America, 
 especially in Colombia, in the Balkan Peninsula and exceptionally 
 in temperate climates. 
 
CHAPTER XXI. 
 ONYCHOSES. 
 
 The nail is a horny plate resulting from a special type of kera- 
 tinization. This particular mode of keratinization is limited in man 
 to the floor of a deep depression in the epidermis of the dorsal 
 aspect of the terminal phalanges. 
 
 The ungual plate or nail-plate is of convex shape, especially in the 
 transverse direction and its root is inserted into this depression, 
 which has the form of a groove or notch. The root is bevelled on its 
 lower surface, the bevelled edge corresponding to that portion of 
 the invaginated epidermis which secretes the nail and which is 
 known as the matrix of the nail (Fig. 137). 
 
 Fig. 137. — Nail of the index finger of a newborn infant; longitudinal section. 
 The middle third of the section has been omitted from the drawing. A, root; B, supra- 
 ungual fold; C, nail; D, subungual groove; E, free border; F, matrix; G, bed. X 13. 
 
 The nail-plate formed in the matrix grows in the direction of the 
 extremity of the finger or the toe. When it has pushed forward 
 from under the supra-ungtial [posterior] fold, the body of the nail 
 rests on the bed of the nail and its borders are insinuated under the 
 lateral (olds. Its extremity is free and passes above the subungual 
 groove. 
 
 The growth of the nail, which is about 3 nun. monthly, therefore 
 depends upon the activity of the ungual matrix. Any lesion of this 
 matrix as a whole will manifest itself in an arrest of growth and may 
 be finally marked by a transverse ridge on the ungual plate when this 
 lesion has been temporary; by an atrophy of the nail when it is 
 
CONGENITAL MALFORMATIONS 431 
 
 permanent. The partial lesions of the matrix will result in a spot 
 when they are temporary, a streak or a longitudinal band when they 
 are persistent. The thickness of the nail seems to depend upon the 
 degree of slanting of the matrix. 
 
 The bed of the nail enters to only a very slight extent into the 
 formation of the nail which is not thicker at its free extremity than 
 at its root. Nevertheless pathological changes of the nail-bed play 
 a certain role in the onychoses. 
 
 The diseases of the nails, known as onychias or onychoses, therefore 
 depend on pathological changes of the ungual matrix and to a small 
 extent on those of the nail-bed; their inflammatory forms are 
 designated as onyxis. 
 
 It is customary to describe with these onyxis the perionyxis, 
 namely inflammations of the supra-ungual and lateral folds which 
 are clinically hardly separable. 
 
 In a general way, the onychoses are very common. They may 
 depend on (1) Congenital malformations; (2) local causes, various 
 traumatisms or parasitic affections (onychomycoses); (3) a locali- 
 zation of various dermatoses; (4) the effect of a general disease; (5) 
 trophoneuroses . 
 
 These very different causes and perhaps also still others of 
 unknown nature, give rise to equally variable lesions. It must be 
 emphasized, however, that no absolute conformity exists between 
 a given cause and its apparent effect upon the nail; identical or 
 related causes may produce very different symptomatic pictures, 
 while on the contrary the same appearance may result from a 
 variety of causes. 
 
 On account of the difficulty of biopsies and the rarity of post- 
 mortem examinations, the pathological anatomy of the onychoses is 
 very imperfectly understood. 
 
 The diagnosis of the onychoses is very often difficult and may 
 remain open, unless the lesion is a rare and characteristic one, or the 
 nature of the affection is elucidated by the presence of other cuta- 
 neous localizations. In spite of the remarkable work of Heller and 
 numerous special contributions, this subject still remains somewhat 
 obscure. 
 
 Congenital Malformations. — These may consist, on both extremi- 
 ties, in the complete absence of one or several nails {anonychia), 
 sometimes the nails are replaced by a horny mass {epidermic nail) ; 
 or they may be found to be atrophic, thin, concave, shovel-shaped 
 {koilonychia) ; or they may be hypertrophied {scler onychia) , thick, 
 blackish, roughened, curved transversely, claw-like {onychogry- 
 phosis), or flakey or longitudinally striated, or wavy, etc. These 
 malformations are not uncommonly familial, transmitted through 
 several generations, sometimes associated with malformations of the 
 
432 
 
 ONYt HOSES 
 
 fingers, dystrophies of the hairs or other hereditary errors of con- 
 formation, as well as with various keratoses. It must be kept in 
 mind that malformations of hereditary origin like the nevi some- 
 times do Dot appear until advanced childhood or still later. 
 
 Traumatic Onychoses. — Wounds, ecchymoses, avulsions of the 
 nails, subungual foreign bodies, traumatic onyxis and perionyxis, 
 ingrown nail, etc., belong to the domain of surgery. 
 
 Onychophagia, a bad and sometimes unconscious habit of gnawing 
 the nails, is usually connected with other stigmata of degeneration 
 or with nervous disturbances. It is observed in children of both 
 sexes and even in adults. It is partly referable to heredity, but 
 also largely to imitation; in some schools, more than one-third of 
 the children bite their nails. 
 
 - 
 
 
 Fig. 13S. — Finger nails worn down by scratching. From a case of prurigo vulgaris 
 with eczematization. 
 
 The gnawed nails no longer have a free border; in the extreme 
 degree, they are reduced to transverse stumps, the pulp of the 
 fingers rising up as a cushion in front. This unclean habit may 
 become dangerous through the absorption of pathogenic germs 
 which have lodged under the nails. Compulsory measures and 
 physical agents are rarely efficient; psychotherapeutic treatment is 
 preferable. 
 
 Worn-off nails, combined or not with various artificial colorations, 
 arc encountered in a large number of manual occupations. 
 
 In chronic pruritus and the prurigos, the free border of the nails 
 may become concave and worn, their surface being as smooth as a 
 mirror (Fig. 138); this appearance indicates habitual scratching 
 to the dermatologist, even when the patient is unaware of the habit 
 or wishes to conceal it. 
 
 The popular name of hang nails is applied to small traumatic 
 
ONYCHOMYCOSES 433 
 
 tears or epidermal elevations of the posterior fold and the lateral 
 folds; they easily become the source of infections, lymphangitis, 
 etc., and should be carefully trimmed [sterilized with iodin] and 
 covered with collodion. 
 
 Onychomycoses. — The ungual lesions produced by the achorion 
 and the trichophytons (Chapter XXV) differ only by mere shades. 
 The diagnosis is based upon the possible coincidence of other locali- 
 zations of favus or trichophytosis, and especially on the microscopical 
 examination. 
 
 Onychomycosis favosa is rare and, as a rule, secondary to favus 
 of the scalp or body which may, however, have healed while the 
 ungual lesion still persists. It begins in the subungual grooves or 
 at the lateral borders, as straw-colored yellow spots which are seen 
 shimmering through the nail-plate; these spots grow, raise the nail, 
 which finally becomes cloudy, thickened, fissured, locally puffed up, 
 loosened and exfoliates. At last nothing is left of it but roughened 
 and striated debris. The growth of the achorion under the nail 
 gives rise to a horny substance (Truffi); the nail plate itself is 
 invaded secondarily; but according to Pellizari, it may be attacked 
 primarily. As a rule, the majority of the finger-nails are involved; 
 very exceptionally the toe-nails. 
 
 The onychomycosis trichophytica is generally caused by trichoph- 
 ytons of animal origin. It is more frequent in adults than in 
 children and often coincides with trichophytosis of the beard or of 
 the hairless skin. Several nails are generally involved, without 
 regard to order. The. lesions begin under the free border or under 
 the lateral borders of the nail, as grayish spots with irregular or 
 vague borders, not so yellow as in favus. A beginning at the root 
 also is said to have been noted. When the nail itself is invaded, its 
 external table may be preserved or not; in the former case, the 
 nail is greatly thickened, opaque, striated like rush-pith, friable at 
 its free border, concave, or on the contrary curved in and claw- 
 shaped; in other cases the external table is fissured and worn and 
 the nail eroded, spongy, roughened, dirty and more or less de- 
 stroyed. 
 
 The onychomycoses are painless. They may undergo a spon- 
 taneous cure, but when left untreated usually last a very long time, 
 up to twenty years or more; they are, moreover, very rebellious to 
 treatment. 
 
 In a general way, oxychomycoses should be suspected in the 
 presence of any chronic onychosis of obscure, supposedly trophic 
 cause, etc. 
 
 Microscopical examination of nail-dust, scraped off and heated 
 on a glass slide in a 40 per cent, potash solution, shows mycelic 
 elements, which are shorter and more irregular in favus than in 
 28 
 
434 ONYCHOSES 
 
 trichophytosis; l>ut the distinction is not easy. Cultures of ungual 
 trichophytons often fail for no known reason. 
 
 The medical treatment of the onychomycoses consists in scraping 
 as much as possible from the thickness of the nail and in having the 
 patient wear every night for many months a dressing of cotton soaked 
 in Lugol's iodin-iodide solution, covered with a rubber finger-stall 
 which does not compress the linger. Various salves or ointments 
 containing reducing or antiseptic agents may also be employed. 
 
 Surgical treatment is more rapid, consisting in avulsion of the 
 nails after local anesthesia; iodin-iodide dressings will prevent 
 re-infection of the new nail. 
 
 Onychoses of the Dermatoses. — There exists a pyococci*; onyxis, 
 generally due to an association of staphylococci and streptococci; it 
 might also be designated as impetiginous' onyxis (Fig. 139). 
 
 Fig. 139. — Pyoroecic onyxis and'perionyxis of the right index finger and the left 
 ring finger, of one year*s standing, in a girl aged ten years. 
 
 Although attention has been called to it, notably by Sabouraud, 
 it is not sufficiently known and is a frequent occasion of diagnostic 
 and prognostic errors. It is encountered especially in children and 
 youthful individuals, but also in adults, on one or several nails of the 
 fingers or the toes. 
 
 Pyococcic onyxis generally follows upon impetigo and especially 
 upon panaris or whitlows; it extends beyond these conditions, its 
 duration being much more prolonged, over a number of months. 
 It begins as minute abscesses under the angle of the nail, which often 
 dry without opening; they spread from one place to another in the 
 vicinity in the nail-bed, more or less detaching the nail, which may 
 itself become irregular, roughened and brittle, when the matrix has 
 been invaded by the process. This onyxis is always accompanied by 
 
ONYCHOSES OF THE DERMATOSES 435 
 
 perionyxis, namely redness, swelling and even pustulation of the 
 peri-imgual folds. 
 
 The treatment consists of local baths with Alibour water and 
 moist dressings; later on, in applications of yellow precipitate oint- 
 ment or various tar preparations. When properly treated, this 
 affection is readily curable. 
 
 Eczema of the nails is frequent, generally accompanied by eczema 
 of the fingers and toes, as well as by perionyxis. The lesions are 
 extremely polymorphous. There may be detachment of the nails 
 with redness and subungual desquamation, longitudinal or transverse 
 ridges with thickening, punctations, erosions, various deformities, 
 etc. The treatment is that of eczema. 
 
 The psoriatifarm eczematides and psoriasis give rise either to 
 dotted cup-like erosions resembling the surface of a thimble, or to 
 transverse and longitudinal striations, or to detachment beginning 
 at one of the borders, etc. 
 
 A positive diagnosis of eczema or psoriasis of the nail cannot be 
 made without taking into account the concomitant lesions, but it 
 must be kept in mind that onychosis may precede the cutaneous 
 manifestations and often survives them. 
 
 The treatment of psoriatic onychosis is very trying. Pyrogallol 
 or chrysarobine salves, of 2.5 or even 10 per cent., may be employed. 
 I prefer to paint the nails with a solution of one of these agents in 
 ether or chloroform, or with some tarry solution, followed by cover- 
 ing with plaster or a varnish. Radiotherapy is sometimes very 
 efficient. 
 
 In pityriasis rubra pilaris the nail is thickened, striated, literally 
 like rush-pith, lustreless and yellowish; the thickening is due to 
 a very hard although porous hyperkeratosis of the bed, which 
 becomes conglomerated with the ungual plate. 
 
 In ordinary alopecia areata, but especially in the extensive and 
 generalized forms, ungual lesions are frequent, consisting of dryness, 
 white longitudinal striation, punctation (pitted nail), or of Assuring 
 (onychorrhexis) crumbling and indentation. 
 
 In the severe primary erythrodermas, the nails become completely 
 or incompletely detached (total or partial onycholysis) and in the 
 last-named case, if a new nail is formed, it insinuates itself under 
 the remains of the old nail. This partition of the nail is also seen 
 after bruising, in syphilitic onyxis, etc. 
 
 In pemphigus , chronic, foliaceous and hereditary, and in the grave 
 forms of Duhring's disease (Fig. 140), the nails are usually involved, 
 although in very different ways. The nail may fall without becom- 
 ing replaced; in this case, the peri-ungual folds become obliterated 
 and the bed is perfectly smooth ; or the nail is detached from before 
 backward, or divided, or atrophied, or even onychogryphotic. 
 
43G 
 
 ONYCHOSES 
 
 In psorospermosis follicularis [Darier's disease], the nails are longi- 
 tudinally striated, furrowed and brittle. 
 
 Chronic radiodermatitis as an occupational disease gives rise to 
 severe ungual lesions, consisting of fragmentation, destruction, 
 exfoliation, or even total atrophy. 
 
 Onychosis of General Diseases. -All severe or even mild pyrexias, 
 eruptive fevers, typhoid fever, pneumonia, anginas, epididymitis, 
 etc.; severe traumatisms or operations; emotional shock, childbirth, 
 etc., may give rise to a groove or a transverse or rather bow-shaped 
 ridge on the nails. All the nails or only some of them, especially 
 the thumbnails, are thus marked to a variable degree. [The severe 
 sea-sickness of an ocean voyage is capable of producing this effect 
 on the nails.] 
 
 J/E^/ tBL 
 
 
 
 . ^/% vA 
 
 ISM 
 
 
 ■■ 
 
 
 
 fS ' ' tPKi 9^^ 
 
 
 T^k 
 
 Fig. 140. — Lesion? of the nails in a severe case of Duhring's disease. Definite loss 
 on the index finger; atrophy on the ring finger and little finger; detachment, 
 onychauxis and onychogryphosis on the thumb and middle finger. 
 
 This groove results from an arrest or momentary disturbance of 
 growth; it emerges under the supra-ungual fold a few weeks after 
 the cause which has produced it, advancing toward the extremity 
 at the rate of growth of the nail, namely about 3 mm. monthly. It 
 furnishes a valuable indication to recent disturbances in the health 
 of the subject. 
 
 Chronic diseases, infectious or constitutional, may also interfere 
 with the formation of the nails and cause atrophy, koilonychia, 
 fissuration known as onychoschizis, simple hypertrophy known as 
 onychauxis or scleronychia and onychogryphosis. 
 
 Diseases of the pleiiropulmonary apparatus give rise to curva- 
 ture with enlargement of the nails, known as the Hippocratic nail. 
 
 Syphilitic Onyxis. Ungual lesions due to secondary syphilis are 
 entitled to special mention on account of their diversity and 
 importance. The condition is onyxis with or without peri-onyxis. 
 Several varieties have been described by Fournier: 
 
DYSTROPHIC ONYCHOSES OF NERVOUS ORIGIN 
 
 437 
 
 The nail may be cracked [scabritees urigium] and brittle at its free 
 end; or detached from below upward (onychoschizis) with non- 
 painful redness and desquamation of the bed and sometimes loss 
 of the nail; or considerably hypertrophied (pachyonyxis) , thickened, 
 striated and blackish, without change of its general shape; or 
 ulcerated (helconyxis) ; in the last-named case, the loss of substance, 
 usually oval, crateriform and with lamellar borders, appears on the 
 lunula and exposes the matrix or the bed of the nail, which is of a 
 grayish-pink color. 
 
 The peri-onyxis is said to be scaly or horny when a squamous 
 papule forms on one of the peri-ungual folds; inflammatory, when 
 it consists of a dusky red, very persistent tumefaction; ulcerative, 
 when a loss of substance with cut-out borders and a sanious floor 
 develops, often as a semicircle, on the peri-ungual folds. The extrem- 
 ity of the finger is swollen and reddened; the nail usually falls out. 
 Several fingers or toes are often attacked at the same time. 
 
 Fig. 141. — Syphilitic onyxis. At the thumb, pachyonyxis and onychoschizis; 
 on the index finger, a large deep groove; on the other fingers, cracked, fissured, 
 crumbling nails. The syphilitic infection of this patient was of ten months' standing. 
 
 These syphilitic onyxes and peri-onyxes (Fig. 141) are slightly 
 painful, develop slowly and are subject to recurrence; they are apt 
 to reappear in the course of the tertiary stage and prove very rebel- 
 lious to treatment. Similar ungual lesions or more common ones 
 are met with in congenital syphilis. 
 
 Dystrophic Onychoses and Onychoses of Nervous Origin— Many 
 nervous diseases involve the nails, notably the traumatic neuroses, 
 syringomyelia, Morvan's disease, Raynaud's disease, tabes, hemi- 
 plegia, scleroderma, etc. Perhaps the general diseases referred to 
 above act through the mediation of the nervous system. 
 
438 ONYCHOSES 
 
 The form of the lesions is extremely variable: simple falling-out, 
 
 atrophy, detachment, fragility, deformity thickening, etc. 
 
 All kinds of onychoses, the nature and origin of which could not 
 be discovered, have commonly been referred to a trophic cause. 
 I yield to this tendency in grouping here the four following forms: 
 
 Leuconychia. -There exist two varieties of this affection: One is 
 punctate and common in children, youthful individuals and women 
 who take great care of their nails; it is characterized by small scat- 
 tered or profuse white spots known under the name of fiores unguium, 
 mendacia (gift-spots), or sometimes by linear series of spots which 
 appear toward the lunula and advance with the nail. Nervous 
 disturbances, some intoxications, etc., have been held responsible; 
 but in my opinion they are the result of slight traumatisms of the 
 ungual matrix. 
 
 The other variety, leukonychia totalis, may be congenital or even 
 hereditary; often it is acquired and occurs after a severe disease, or 
 a neuritis, etc. There is also a striated variety, with alternately 
 white and normal transverse bands. 
 
 The whiteness of the nail is due in both types to fine bubbles of 
 air which have become infiltrated between the probably imperfectly 
 keratinized ungual cells. 
 
 The patient should be instructed to avoid traumatism of the 
 matrix of the nails, for example, in the manipulation of pushing back 
 the supra-ungnal cuticle [and the use of the pernicious cuticle knife]. 
 The nails can be tinted with an alcoholic solution of eosin. 
 
 Onychogryphosis. — This name was given by Virchow to a 
 deformity consisting of a sometimes enormous and very hard 
 thickening, with a change in the direction of the nail, which becomes 
 raised and curved on itself. The onychogryphotic nail of a low 
 degree assumes the appearance of a very hard grayish or brownish 
 claw, curved transversely and from before backward and raised 
 from its bed by hyperkeratosis. 
 
 In a higher degree, the nail is entirely deformed, convex and 
 twisted, resembling a ram's horn. It is implanted almost vertically 
 on its bed, of a brownish color and marked at the same time by 
 longitudinal stria* and transverse undulating striae; the latter indi- 
 cate the changed direction of the plane of the matrix. The nail 
 grows slowly, but as its stony hardness prevents it from being cut, 
 it often reaches from 3 to 4 cm. in length and exceptionally may 
 attain a length of 10 and 12 cm. It is easily understood that it 
 becomes troublesome in proportion to its size. 
 
 Onychogryphosis is observed especially at the feet, on the big toe 
 and sometimes on the neighboring toes (Fig. 142). It is less common 
 at the fingers, where I have, however, seen several cases of it. The 
 pathogenesis proposed by Virchow, who holds pressure from the 
 
ONYCHOSCHIZIS 
 
 439 
 
 shoes responsible for an irritation of the matrix, is therefore not 
 tenable. Inflammatory lesions of the nail-bed, which were demon- 
 strated by Unna, are perhaps secondary. It seems that a hyper- 
 keratosis of the bed with hyperplasia of its papillary crests, accord- 
 ing to Heller, raises and straightens the nail, which then grows 
 thicker, but also more slowly. At any rate, this ungual dystrophy 
 appears especially at a mature or advanced age ; it is almost regularly 
 present on varicose limbs, bearing ulcers or the seat of elephantiasis; 
 or it may coincide with chronic rheumatism, arteriosclerosis, neuritis, 
 leprosy, etc. 
 
 The palliative treatment consists of scraping, sawing, or tearing off 
 the nail; it may first be softened by means of potash or salicylic 
 acid. In order to prevent re-growths, it is necessary to excise the 
 ungual matrix. 
 
 Fig. 142. — Onychogryphosis of'the first three toes. 
 
 Onychorrhexis. — Dubreuilh and others give this name to longi- 
 tudinal striation with fragility of the nails. 
 
 In pronounced cases, the nail is lustreless, cracked, roughened, 
 thinned and broken. A few or all the nails may be involved. Ony- 
 chorrhexis may date from childhood, or it may develop as a sequel of 
 nervous disturbances, lichen planus, alopecia areata, etc. The nails 
 may be painted with collodion to remedy the painful cracks and 
 fissures. 
 
 Onychoschizis. — This term (axtf «u = to separate) designates the 
 detachment of nails from their bed. This separation is, as a rule, 
 progressive and more or less rapid, with periods of remission and 
 exacerbations. It begins under the free border and gradually 
 ascends as far as the lunula; a single finger may be involved, or 
 usually several fingers and toes are attacked simultaneously or 
 progressively. Sometimes the separation is evidently dependent 
 upon a subungual hyperkeratosis with accumulation of solid or 
 friable horny material. 
 
140 ONYCHOSES 
 
 Onychoschizis, like onychorrhexis and a considerable number 
 
 of other changes of the nails, mentioned above, are undoubtedly 
 not always of the same etiology and significance. Every case should 
 be traced to its cause, if possible. 
 
 General Diagnosis of the Onychoses. — Sometimes the objective 
 features of ungual lesions, or the circumstances and coincidences 
 are such that they can be referred to a definite cause from the start. 
 Not infrequently, however, in clinical cases the etiology is neither 
 apparent nor easily discovered. A hasty diagnosis of "trophic 
 disturbance of the nails" — as is only too frequently made and merely 
 amounts to an admission of ignorance — should be refrained from in 
 such cases. When confronted with an onychosis of obscure char- 
 acter, the physician must pass in review the different classes of lesions 
 enumerated in this chapter, in order to find out where it belongs. 
 
 It is well to remember the following facts: Malformations of the 
 nails of congenital origin, or those connected with familial and hered- 
 itary dystrophies may appear a fairly long time after birth; per- 
 manent deformities of the nails may result from traumatisms which 
 have damaged their matrix; onychomycoses of indefinite duration 
 may occur without tinea, sycosis or epidermomycosis, and require 
 microscopic examination; the onychoses of the dermatoses, pyo- 
 coccia, eczema, eczematides, psoriasis, lichen planus, Duhring's 
 disease, etc., not infrequently persist after the cutaneous manifes- 
 tations have disappeared and may exceptionally precede them; 
 syphilis and congenital syphilis require very careful investigations 
 and sero-diagnosis. 
 
 Finally, the discovery of chronic constitutional diseases (diabetes, 
 etc.) or infectious diseases (tuberculosis, etc.), as well as nervous 
 diseases, even abortive or incipient, may sometimes supply diag- 
 nostic indications and suggest the proper treatment. 
 
 A systematic review of this kind will considerably reduce the 
 number of cases described as trophic disturbance of the nails, or 
 trophoneurotic onychosis. 
 
 The treatment must frequently utilize either keratolytic or reducing 
 agents. Often, even in cases of enigmatic character, considerable 
 benefit is obtained from high frequency currents and especially from 
 radiotherapy. 
 
CHAPTER XXII. 
 HIDROSES. 
 
 The name hidroses (jdptoq = sweat) may be applied to func- 
 tional disturbances of the sweat-secretion and to the primary 
 organic lesions of the sudoriparous apparatus. 
 
 The sweat glands are epithelial tubes whose deep or secretory por- 
 tion is rolled up as a glomerulus, situated in the lower layers of the 
 corium or the upper layers of the hypoderm; their ascending excret- 
 ory portion, the so-called siveat-duct, passes directly through the 
 derma and twists as a spiral in the epidermis. This channel opens 
 obliquely at the surface through a pore. This arrangement of the 
 pore and the sweat-channel and, moreover, the direction of the fluid 
 which passes through them, oppose the penetration of dust and 
 microbes into the interior, so that infections of the skin rarely occur 
 by this route. 
 
 The sweat-glands are distributed in unequal numbers over the 
 entire integument, including the palmar and plantar regions, where 
 they are indeed especially abundant. In the axillary fossae and in 
 the anogenital region, they are of a special type, their secretory 
 portion here having a very large lumen and serving as a receptacle 
 for the sweat. 
 
 The sweat is a watery fluid, of an odor varying according to body 
 regions, individuals and races; usually of an acid reaction except in 
 case of profuse sweating; in the axillae and in the groins, the reaction 
 is normally alkaline. 
 
 The quantity of sweat excreted in a given time varies enormously, 
 and is influenced by temperature, exercise or rest, amount of bever- 
 ages, action of the nervous system, as well as some -pathological 
 conditions and medicinal agents. The average quantity is estimated 
 at about a litre in twenty-four hours. 
 
 Under normal conditions, the sweat evaporates in proportion to 
 its production. Neither this insensible perspiration nor profuse 
 sweating act as emunctories, but they greatly contribute to the 
 regulation of the body temperature. Another function of the sweat 
 is the maintenance of a moist and supple horny layer, as well 
 through its watery content as through the emulsified fat contained 
 in it. 
 
 The chapter on hidroses is not of particular interest to the 
 dermatologist. A distinction must be made between functional and 
 organic hidroses : 
 
442 HIDROSES 
 
 1. Disturbances of the sweat secretion, or junctional hidroses, 
 belong to a considerable extent to the domain of general medicine. 
 
 2. Organic lesions of the sweat-glands, or organic hidroses, are on 
 the whole rare. 
 
 Among the latter, hidrocystoma and hidradenoma will be described 
 with the tumors; among the keratodermas, in a preceding chapter, 
 mention has been made of porokeratoses or punctuate keratoses, 
 which are without sufficient reason interpreted as ostio-sndoriferons 
 keratoses. Dysidrosis and miliaria likewise have no definite 
 relations with the sweat structures. The following discussion 
 will accordingly be limited to sudamina, hidradenitis and miliary 
 abscesses. 
 
 FUNCTIONAL HIDROSES. 
 
 The anomaly concerns either the quantity, or the odor, or the 
 color of the sweat. 
 
 Anidrosis. — Very exceptional cases have been reported of indi- 
 viduals who do not perspire and therefore imperfectly regulate their 
 temperature, as a result presenting symptoms of heat-stroke on 
 even moderate exposure to the sun in summer-time. A striking 
 observation of this kind was recentlv published by R. Lutenbacher 
 (May, 1917). 
 
 The sweat is very scanty in persons suffering from diabetes, 
 myxedema, cachexia, ichthyosis, as well as in senile degeneration 
 of the skin. Sweating is temporarily absent in several chronic 
 erythrodermas, on the patches of psoriasis and in a considerable 
 number of other eruptions. 
 
 Hyperidrosis. — Individual differences in the amount of sweat 
 excreted are such that hyperidrosis is never more than relative. 
 
 The profuse transpirations which occur in the course or at the 
 decline of the pyrexias, sweating or miliary fever, acute rheumatism, 
 the sudoral form of typhoid fever, pneumonia, grippe, septicemias, 
 etc., the sweats of phthisis, gout, or the moribund do not belong to 
 the realm of this discussion. 
 
 In a considerable number of organic or functional nervous diseases, 
 in hemiplegia, tabes, neuritides, wounds of the nerves, lesions of the 
 sympathetic, neurasthenia, exophthalmic goitre, etc., there occur 
 profuse sweats, generalized or partial, permanent or in attacks. 
 This is suggestive of a nervous pathogenesis in the so-called essential 
 hyperidroses. Moreover, these are preferably observed in highly 
 emotional individuals, or associated with obesity or auto-intoxica- 
 tion. The sweat may exude all the time or, on the slightest effort 
 or trifling emotion, moisten the surface of the skin, sometimes 
 flowing in profuse drops. Maceration of the epidermis in the folds 
 is a common sequel. 
 
FUNCTIONAL HIDROSES 443 
 
 Hyperidrosis may be general, or more frequently partial, when 
 it is known as ephidrosis. There is, for instance, a total facial ephid- 
 rosis, or hemifacial or localized ephidrosis. The secretion in these 
 patients may occur as a reflex under the influence of mastication 
 or certain gustatory sensations, among others that of vinegar or 
 chocolate. 
 
 It is a familiar fact that bald persons usually transpire freely from 
 the scalp and face ; I believe that this hyperidrosis is connected with 
 kerosis and dependent upon its multiple causes (p. 196). 
 
 The sweat of kerotic individuals is sometimes charged with such 
 an abundance of emulsified fluid fat as to cause grease-spots on 
 pillows, hats, paper placed on the skin, etc. These cases are desig- 
 nated by the name of hyperidrosis oleosa. The condition is probably 
 a combination of hyperidrosis with seborrhea oleosa (p. 393). 
 
 The peculiar affection which bears the name of granulosis rubra 
 nasi seems to be regularly associated with hyperidrosis and is prob- 
 ably a result of the latter. It is observed especially in children and 
 is characterized by small pinkish or red miliary papules on a lavender 
 and cold background; the lesions occupy the nose and sometimes 
 the lips or the chin; they become less marked with advancing years. 
 
 The extremities are constantly moist or even wet with sweat in 
 some individuals. When the hands are affected, a number of occu- 
 pations are rendered impossible; at the feet, the excessive sweat 
 macerates the epidermis, makes the skin very vulnerable, markedly 
 impedes walking and often becomes offensive. Hyperidrotic ex- 
 tremities are rarely warm and congested ; as a rule, they are cold, 
 acro-asphyxiated and flabby, or of a waxy white color. 
 
 Hyperidrosis of the articular folds, especially of the axillse, is 
 extremely common; many obese, gouty, rheumatic or nervous 
 individuals suffer from this condition. Axillary hyperidrosis may 
 lead to lepothrix and to chromidrosis. It predisposes to intertrigo, 
 to deep abscesses, etc. 
 
 All dermatologists are familiar with hyperidrosis nudorum, a free 
 flow of sweat from the axillae seen in patients who are stripped and 
 exposed before an audience. In these cases, an excretory rather 
 than a secretory reflex is concerned ; under the influence of cold and 
 emotion, the smooth muscle fibers of the large axillary glands become 
 contracted and empty their contents. 
 
 Bromidrosis. — This name is applied to the offensive sweats which 
 occur especially at the feet, sometimes in the axillse or groins, con- 
 stituting a most distressing infirmity. 
 
 Usually, but not invariably, bromidrosis is connected with hyper- 
 idrosis and is a complication of the latter. It is possible for fatty 
 acids or ammoniacal compounds to become eliminated in excess 
 through the sweat, but as a rule the offensive odor is derived from 
 secondary decomposition. 
 
444 hid roses 
 
 In the treatment of hyperidrosis and bromidrosis, it is important 
 not to neglect the correction of whatever may be deficient in the 
 genera] hygiene of the patients. Locally warm or lukewarm baths 
 are recommended; alcoholic rubs, for example with camphorated 
 alcohol, or with alcohol containing iodin or tannin; and applications 
 of ichthyol or various powders. 
 
 < !ases of offensive sweating of the feet require scrupulous cleanliness, 
 a frequent change of foot-wear, the wearing of shoes permeable to 
 evaporation. Baths, alcoholic rubs, bland powders charged with 
 salicylic or tartaric acids, or with bismuth subnitrate, are often 
 inefficient. Formol, in all its forms, is dangerous. 
 
 A good treatment of plantar hyperidrosis and bromidrosis con- 
 sists in painting the parts daily with a solution of potassium perman- 
 ganate (1 to 10 per 1000); or with iron perchloride solution with 
 25 per cent, of glycerin. 
 
 Still better results are obtained by painting the parts, daily at 
 first, then at longer intervals, with a solution of chromic acid (2 per 
 cent., or even 5 or 10 per cent.) followed by dusting with talcum- 
 powder; but these applications must be very cautiously made. 
 
 Against palmar hyperidrosis, radiotherapy has been shown by 
 Sabouraud to be the cardinal remedy; sometimes, a single applica- 
 tion of 5 units II. is sufficient. The same treatment is appropriate 
 for granulosis rubra nasi. 
 
 Chromidroses. — The problem of the chromidroses or colored 
 sweats, to which several publications were devoted by Le Roy de 
 Mericourt, still remains very obscure. Many of the reported cases 
 are doubtful or simulated, but a few authentic observations are on 
 record. 
 
 The colored sweats are always regional, partial, or even very 
 circumscribed; they may be blue, red, or black, or sometimes yellow; 
 green, etc. The color as a rule is the result of oxidation on contact 
 with the air of a chromatogenic agent contained in the sweat, which 
 then becomes deposited on the epidermis in a pulverized form. 
 
 A blue coloration is apparently due either to pyocyanin and 
 coexistent with blue suppuration, or to indican. A red color is more 
 common, especially in the axillae; it seems to be of microbic origin 
 and is frequently associated with lepothrix. Dry erythidroses with 
 adherent pigment have also been reported. The case of melanidrosis 
 which was studied by R. Blanchard on the eye-lids of a thirteen-year- 
 old boy confirms beyond a doubt the existence of this form. The 
 black pigment which he saw becoming deposited around the sweat- 
 pores was examined by Maillard and found to be related to the 
 choroid pigment. 
 
 Hematidrosis. — It is conceded that an oozing of blood derived 
 from the capillaries may take place on the intact skin by way of the 
 
ORGANIC H1DR0SES 445 
 
 sweat pores, hence the name which has been given to this phe- 
 nomenon. The majority of the cases reported by the ancients, of 
 bloody sweats under the influence of extreme emotional distress, are 
 undoubtedly mythical. Perhaps the condition actually occurs in 
 the course of severe infections, or in neuropathic individuals, in the 
 presence of purpura, or as a vicarious menstruation. I am not 
 acquainted with any convincing observations. 
 
 ORGANIC HIDROSES. 
 
 In a large number of dermatoses, the sweat-glands are affected 
 together with the neighboring tissues, or secondarily. Primary and 
 idiopathic affections of the glomeruli and sweat-ducts are on the 
 contrary rare. 
 
 It has previously been stated that in dysidrosis the sweat-glands 
 play no part; also, that miliaria rubra and alba, although designated 
 as sudoral eruptions on account of the conditions under which they 
 are usually observed, are in reality a miliary impetigo without con- 
 stant relation to the sweat glands (pp. 85 and 87). 
 
 Sudamina [Miliaria Crystallina] is the name applied to an 
 affection characterized by extremely minute bullous elevations of 
 the horny layer, containing a clear watery fluid and without a con- 
 gested base. 
 
 The sudamina are the average size of a farina grain. Sometimes 
 they are scattered in very variable numbers, sometimes grouped or 
 even confluent in small blebs; they are observed on the trunk, 
 notably on the flanks and abdomen, as well as on the flexor surface 
 of the limbs. They appear suddenly without pruritus, altogether 
 or in successive crops. Their duration is ephemeral; they dry out, 
 the epidermis peels a little and all is well again. It is not impossible 
 for a few small vesicles to acquire turbid contents and a slightly 
 reddened base, as the sequel of a secondary infection which trans- 
 forms them into miliary impetigo; but this is an exceptional 
 occurrence. 
 
 Sudamina have been encountered in the course of severe pyrexias, 
 such as acute rheumatism, typhoid fever, scarlatina, at the crisis 
 of pneumonia, or as a phenomenon preceding death. They are also 
 observed to occur under occlusive dressings in the hot season, or 
 in the course of treatment with keratoplastic agents. 
 
 A sudamen, as shown by J. Renaut, is a small bleb situated in the 
 horny layer or immediately below it, on the course of a sudoriparous 
 canal. It may be interpreted as the mechanical result of splitting 
 of this layer under the influence of a gush of sweat occurring after a 
 temporary anidrosis with stagnation of the horny layer, or exagger- 
 ated keratinization. The sudaminal contents are therefore probably 
 
IKi HIDROSES 
 
 sweat, which by some authors was found to be alkaline or neutral, 
 by others, including Jadassohn, invariably acid. 
 
 No importance, not even a prognostic value, can be attached to 
 this trifling lesion. 
 
 Hidrosadenitis. — Verneuil (1864) described as phlegmonous hidros- 
 adenitis or sudoriparous abscesses an affection commonly observed 
 in the form of tuberous abscesses of the axilla (Velpeau) and which 
 according to him may also be localized at the circumference of the 
 anus, at the external auditory meatus, or even become disseminated. 
 
 This condition is a form of staphylococcic pyodermatitis which 
 will be described elsewhere in this book. It is usually admitted to 
 result from an infection by way of the sweat-channels, although 
 this fact cannot easily be demonstrated directly. [This disease 
 should not be confused with hidradenitis suppurativa (Pollitzer), 
 which is now included in the papulo-necrotic tuberculides.] 
 
 Miliary Abscess of Little Children. — This condition has been 
 known for a very long time and was already distinguished by 
 Alibert from furunculosis. It occurs in neglected or greatly 
 weakened infants suffering from impetigo, eczema of the buttocks, 
 gastro-enteritis, bronchopneumonia, etc., and consists of multiple 
 scattered resistant intradermic nodules, all of about the size of a 
 small pea. On puncture a creamy pus is evacuated, their cavity is 
 more or less deeply situated in the cutis. They occur in crops, some- 
 times repeated; the general phenomena are very variable. 
 
 The pyemic character of these abscesses was suspected in the past. 
 However, Escherich and Longard surmised and Lewandowski (1906) 
 demonstrated that they are in most cases the result of a staphylo- 
 coccus aureus infection ; the infection takes place through the sweat- 
 pores, a point of lessened resistance in the infantile skin. The almost 
 invariable coexistence of small intra-epidermic pustules the size of a 
 pin-head has been demonstrated, analogous to the ostiofolliculitis 
 of Bockhardt, but due to infection of the sweat-pores and designated 
 by Lewandowski as periporitis. 
 
 As to treatment, incision of the abscesses is recommended, next 
 sweating followed by sublimate baths of 1 per 10,000. Zinc sulphate 
 baths of the same strength, or washes with Alibour water, would 
 undoubtedly prove equally efficient. 
 
PART IT. 
 NOSOLOGY OF THE DERMATOSES. 
 
 In the first part of this book I have discussed the morphology of 
 the dermatoses with a comparison of those related either by a com- 
 mon eruptive lesion or pathological condition of the skin, or by a 
 conformity, of localization in the same cutaneous or mucous territory 
 or in the same organic adnexa of the epidermis. 
 
 In the following part the dermatoses will be grouped according 
 to their etiology, considering together those which are dependent 
 upon the same kind of causes. 
 
 CHAPTER XXIII. 
 ARTIFICIAL DERMATITIDES. 
 
 Inflammations of the skin resulting from the injurious action 
 of a mechanical, physical, or chemical cause are called artificial 
 dermatitides. 
 
 Their clinical features are extremely variable; they may assume 
 practically all the forms of dermatological lesions, especially those 
 of erythema, urticaria, purpura, eczema, blebs, gangrene, etc. 
 
 The severity of the lesions, their superficial or deep character, 
 their more or less rapid or slow onset, their ephemeral or prolonged 
 duration, depend in part upon the cause and in part upon the soil 
 on which it has acted. The cause may in itself be more or less 
 markedly injurious; its action may have been more or less intense or 
 persistent. The soil, namely the damaged skin, in its turn presents 
 variations in vulnerability and capacity of reaction according to the 
 patient and the region of the body. 
 
 Those relatively rare cases must be separately classified in which 
 there exists what Brocq calls (July, 1915) a diminished resistance of 
 the skin, which may be congenital or regional; this abnormal vul- 
 
Ms ARTIFICIAL DERMATITIDES 
 
 nerability — which is the basis of congenital pemphigus, hydroa 
 vacciniforme and xeroderma pigmentosum, but which I have 
 observed also outside of these affections — often manifests itself only 
 toward a certain class of injurious agents (traumatism, light, etc. I. 
 
 In normal individuals, it may be stated that the influence of the 
 patient's individuality, his persona] equation, what is known as the 
 morbid predisposition, is relatively slight in the case of most dermat- 
 itides of mechanical and physical origin; whereas this predisposition 
 plays on the contrary a leading part in the pathogenesis of dermat- 
 itides 'of chemical origin, or toxidermas. It will be more fully 
 considered in the section devoted to the latter. 
 
 It must be understood that there is no absolute and constant 
 agreement between cause and effect in the artificial dermatitides. 
 From this rule are derived the two following corollaries: 
 
 The same injurious agent may give rise, in different cases, to 
 fundamentally dissimilar eruptions. The dose, the avenue of inva- 
 sion, still other factors and especially the individual predisposition 
 strongly modify the consequences of the same cause. In this way, 
 to quote an immediate example, the absorption of an iodide may 
 give rise, in different cases, to erythema, urticaria, purpura, bulla?, 
 pustules, etc. 
 
 Inversely, dermatitis of identical appearance may be derived 
 from entirely different injurious causes. A bullous dermatitis, for 
 instance, may be the result of a burn, the application of a blistering 
 or caustic substance, or the absorption of a medicinal agent such as 
 an iodide or antipyrin. It could not be otherwise, for while injurious 
 agents are extremely numerous, the modes of reaction of the skin are 
 limited in number. 
 
 In dealing with a given cutaneous lesion, the clinician is therefore 
 often puzzled at its origin. It is precisely this difficulty which lends 
 interest to the artificial dermatitides which are extremely common. 
 
 I shall successively review (1) dermatitides due to mechanical 
 causes; (2) dermatitides due to physical causes; (3) dermatitides 
 due (or apparently due) to chemical causes, which may be called 
 toxidermas; these should be subdivided into two groups, according 
 to their external or internal origin. It seems advisable to add to the 
 description of the latter a comment on the autotoxic dermatoses, 
 which although not artificial may pass as toxidermas. 
 
 DERMATITIDES DUE TO MECHANICAL CAUSES. 
 
 Traumatisms of all kinds, when slight, may give rise to erythema 
 (Chapter I). More severe traumatisms cause contusions, wounds, 
 etc., in short, surgical complications. 
 
 The following belong to the domain of dermatology: Traumatic 
 
DERMATITIDES DUE TO MECHANICAL CAUSES 449 
 
 eczema (Chapter IV) ; excoriations from scratching and the epi- 
 dermic hypertrophy known as lichenization; the latter will be 
 discussed in the chapter on Pruritus (Chapter XXIV); certain 
 traumatic alopecias; and furthermore, the effects of repeated or 
 prolonged pressure. 
 
 Strong and persistent pressure on some part of the skin, like that 
 exerted by a badly fitting plaster apparatus, gives rise at first to 
 erythema, then to phlyctinization, finally to ulceration and even to 
 gangrene. 
 
 Repeated pressure with friction on a thick epidermis, like that 
 produced on the foot by hard shoes during a long march, or on the 
 hand by the manipulation of some tool or instrument, causes the 
 appearance of bullous elevations known as traumatic blisters, well 
 known to soldiers, mountain-climbers, boatmen, acrobats, etc. 
 
 Attention is here called to the special vulnerability of the skin 
 which constitutes congenital pemphigus (p. 191). 
 
 Callus. — Callus or callositas represents a chronic traumatic der- 
 matitis with thickening of the derma and hyperkeratosis. Callosities 
 are observed on the hands of laborers, where their seat often betrays 
 the occupation of the individual (diggers, gardeners, blacksmiths, 
 tailors, etc.); on the feet, notably on the instep and at the ankles; 
 moreover, on the prominence of the head of the first metatarsal in 
 case of hallux valgus, where they contribute toward the formation 
 of bunions; on the ischial bones of cavalrymen, etc. In short, 
 callosities may form at any point on the body. 
 
 Callus is a yellowish or pigmented prominence of variable extent, 
 round or oval, with gently sloping borders, thick and solid on palpa- 
 tion. Being a defensive reaction of the integument, the callus is not. 
 painful either spontaneously or on pressure unless it is inflamed. 
 In this case — the "durillon force" of Chassaignac — a blister may form 
 underneath the thickened epidermis; when it becomes infected, the 
 subepidermic abscess often gives rise to lymphangitis with fever, 
 so that the patient is obliged to stay in bed. 
 
 The only treatment of simple callus consists in the suppression 
 of its cause. Moist dressings and rest are the measures most to be 
 recommended in case of inflammation. 
 
 Clavus. — A corn or clavus is a local traumatic hyperkeratosis 
 with inflammation, then atrophy of the cutis, occurring only on the 
 feet, at points exposed to chronic pressure from badly fitting shoes. 
 It is situated especially on the prominence of the phalangeal articu- 
 lations of the toes, particularly on the little toe, or on the metatarsal 
 prominences and sometimes on the sole of the foot. Its dimensions 
 vary from those of a lentil to a small bean. Corns are always painful, 
 either spontaneously in damp weather, or on pressure when they are 
 not trimmed. 
 29 
 
450 ARTIFICIAL DERMATITIDES 
 
 Corns differ from callosities in the much greater thickness of their 
 horny layer which projects as a smooth or scaly prominence and is 
 deeply embedded in the cutis; the latter is depressed like a funnel 
 and inflamed or atrophied. In the center of the horny mass a softer, 
 white, medullary portion can often be distinguished, formed by 
 poorly keratinized cells. Underneath the corn the malpighian layer 
 is thinned and the papillae are obliterated. Occasionally the center 
 of the corn presents a papilla with dilated vessels projecting into the 
 horny mass. The so-called "root" of the corn has no actual exist- 
 ence and its extraction by quack chiropodists is nothing but a trick. 
 
 [nterdigital corns, known in France as "ceil de perdrix" (par- 
 tridge eyes), are softened as the result of maceration [soft corns]. 
 
 Corns must not be confused with plantar warts or with mal 
 perforans. 
 
 To be afflicted with corns may mean an extremely distressing if 
 minor infirmity, for which patients are apt to neglect seeking pro- 
 fessional advice. Left untreated and irritated by pressure, corns 
 may become the seat of an inflammation, a blister, an abscess, etc. 
 When badly cut, they often give rise to lymphangitis. 
 
 The popular treatment consists in trimming the hyperkeratotic 
 layer with a razor at regular intervals before it again becomes 
 exuberant and painful, as well as in avoiding all local pressure. The 
 horny mass may also be softened by nocturnal moist dressings, or 
 by keratolytic agents such as salicylic acid plasters, or salicylated 
 collodion, which permits the removal of the corn in a warm 
 bath. Without patient and persistent treatment, a relapse is very 
 probable. 
 
 DERMATITIDES DUE TO PHYSICAL CAUSES. 
 
 Heat, cold, solar and electric radiations, x-rays, beyond a certain 
 limit, are injurious to the human integument. They give rise to a 
 series of lesions, that range from erythema to gangrene. Super- 
 added pyococcic infections frequently complicate the clinical 
 picture. 
 
 Aside from these general data, which apply to all, it is noteworthy 
 that especially in regard to light radiations, certain individuals are 
 much more susceptible than others (solar erythema, pigmentations) ; 
 also, that there actually exist special pathological conditions (herpes 
 vacciniformis, xeroderma pigmentosum) characterized by dispro- 
 portionate reactions to the effect of light. 
 
 Burns. — Burns may be produced by burning or incandescent 
 bodies or by heated substances, solid, liquid, or gaseous. Lesions 
 caused by bright light, electricity, or caustic agents, are often placed 
 in the same group. 
 
DERMATITIDES DUE TO PHYSICAL CAUSES 451 
 
 Three degrees of burns are recognized: 
 
 In the first degree, the lesions consist of erythema, with severe pain, 
 heat, swelling, representing erythema a calore. In a few days, after 
 desquamation, the skin is well again. 
 
 The second degree is characterized by bulla? . These form either 
 immediately, the vaporization of the intramalpighian plasma having 
 raised the horny layer under which a certain amount of serum 
 collects; or secondarily, after a few hours, through the mechanism 
 of superficial or deep bleb-formation. The contents of the bullae, 
 which vary greatly in size, are lemon-yellow, fluid or gelatinous. 
 The pain is extremely severe. The bullae having ruptured, the fluid 
 escapes and a bright, red, shining surface appears under the epidermic 
 membrane; or they may shrivel and dry in crusts; or they may 
 become infected and suppurate. In the last-named case, a cicatrix 
 may persist. The course of healing lasts one or two weeks. 
 
 In burns of the third degree, there is sloughing, coagulation and 
 necrosis of the cutis and sometimes of the subjacent parts. Blisters 
 appear only on the borders of the slough which in different cases 
 is yellowish or brown, or dry and anesthetic. The pain may be less 
 severe than in a burn of the second degree, on account of destruction 
 of the nerve-ends. The course, of very variable duration according 
 to the depth and extent of the burn, the region affected and the 
 evactual complications, is that of a non-progressive gangrene. The 
 cicatrix is often vicious. 
 
 Very extensive burns, like those of children who have tumbled 
 into a boiler, or of soldiers struck by an incendiary shell, or those 
 which I saw after the fire of the Puteaux powder mills, where the 
 unfortunate women workers were burned from head to foot except 
 on the parts protected by the corset, are accompanied by grave 
 general symptoms. Chills, fever or rather a lowering of the central 
 temperature, collapse or delirium, bloody vomiting, melena, albu- 
 minuria and pulmonary complications are due in such cases for the 
 most part to toxic products resulting from the alteration of the 
 blood in the cutaneous vessels, under the influence of heat; in part 
 to the nervous shock and finally to superadded infections. Burns 
 involving over one-third of the total tegumentary surface are 
 usually fatal. 
 
 The treatment of burns consists in cleansing the skin, in the evacua- 
 tion of the blisters without pulling off the epidermis, in the appli- 
 cation of sterile occlusive dressings. Packing in aseptic cotton, 
 after painting with dilute tincture of iodin (1 to 2) constitutes 
 an excellent procedure of immediate treatment; if necessary, the 
 clothing must first be cut away. 
 
 Among the countless topical applications which have been 
 recommended, including even raw scraped potato and gooseberry 
 
452 ARTIFICIAL DERMATITIDES 
 
 jelly, which actually relieves the pain, the preference must be 
 accorded to oil- and lime-water liniment, vasolanolin, naftalan, or 
 better still, to the special oils named pyrolcol and phlyctol, which 
 are highly analgesic. The burn is covered with sterilized com- 
 presses soaked in one of these products and with a thick layer of 
 cotton. The dressings should be changed as rarely as possible, 
 except in case of suppuration. Ichthyol, glycerinated thiol, the 
 salve of J. Lucas-Championniere and the product named ambrine, 
 can also be recommended. Picric acid which has found so much 
 favor, should be rejected, for it is sometimes dangerous. 
 
 In case of very extensive burns, permanent lukewarm baths give 
 the most relief. It goes without saying that an injection of mor- 
 phin should not be refused to these unfortunates in their atrocious 
 sufferings. Camphorated oil and adrenalin by subcutaneous injec- 
 tions and enemas with physiological salt solution, are indicated in 
 grave cases. 
 
 Frost-bite. — Lesions caused by freezing differ in many respects 
 from those due to extreme heat. Cold requires a longer time for 
 its action. Immediate pain is practically absent and nothing is felt 
 but an unpleasant numbness; pruritus and an intolerable burning 
 sensation being delayed until the reestablishment of the circulation. 
 It is almost invariably the extremities that are attacked by frost- 
 bite; the feet, the hands, the ears and the nose. In the first degree 
 the region is of a cadaveric pallor, followed by intense congestion. 
 The second and third degree, bleb-formation and sloughing, usu- 
 ally exist together, the lesions attaining their maximum at the 
 periphery, at the tips of the toes, the fingers, etc. The integument 
 is at first of a waxy color, the region is anesthetic and lifeless. It 
 is impossible to determine to what depth the tissues are affected 
 till after a few days. 
 
 The frozen parts must be very cautiously and progressively 
 warmed, preferably by rubbing them with snow; they may be 
 covered only very gradually and the surrounding temperature 
 raised very slowly. The subsequent course and the treatment are 
 the same as in gangrene of any origin. The physician's attitude 
 should be as conservative as possible and surgical intervention be 
 restricted to the removal of a sequestrum. Frost-bites may lead 
 to grave mutilations. 
 
 Chilblains and trench-foot have been discussed elsewhere in this 
 book (pp. 34, 35). 
 
 Radiodermatitides. — The .-c-jrays as well as radium, mesothorium, 
 etc., although causing no sensation whatever at the moment of 
 application, may give rise to a series of cutaneous manifestations, 
 the extreme degrees of which are very grave. However, as there 
 seems to be no individual idiosyncrasy toward these radiations, 
 
DERMATITIDES DUE TO PHYSICAL CAUSES 453 
 
 these disturbances can always be avoided. They depend exclu- 
 sively upon the dosage and quality of the rays. It is therefore of 
 the utmost importance for radiologists to employ all measuring 
 instruments belonging to an outfit of this kind, to be entirely 
 familiar with the peculiarities and strength of their apparatus, to 
 calculate accurately without mistakes the distance from the anti- 
 cathode to the skin as well as the time of the exposure. 
 
 Unfavorable sequelae of .r-ray treatment and the occupational 
 radiodermatitides of radiologists themselves will be discussed 
 separately in the following. 
 
 Therapeutic Radiodermatitides. — The cutaneous reactions due to 
 the x-rays do not appear until after a period of latency or incuba- 
 tion, lasting from eight to twenty days, usually from fifteen to 
 seventeen days. The slight redness which may supervene on the 
 same day or the day after the session is an erythema presumably 
 due to the light rays and is of no importance. 
 
 Alopecia of the scalp regularly appears upon a dose of 5 H, so 
 that Sabouraud was enabled to formulate the radiotherapeutic 
 treatment of the tineas. On the face and elsewhere, alopecia is 
 not a constant result and is often complicated by pigmentation and 
 cutaneous atrophy. 
 
 Beyond a dose of 5 H in a single session, or if exposures of the 
 same point are repeated beyond the ratio of tolerance as established 
 by experience, there is danger of a series of manifestations, to be 
 enumerated in the following: It must be kept in mind in this con- 
 nection that the .T-rays have a cumulative effect; that nevertheless 
 there is a loss with time, differently estimated by authors, but which 
 can be rated at 1| H weekly; finally, that certain regions are 
 especially susceptible, notably the back of the hands and feet, the 
 bridge of the nose and the forehead — perhaps all points where 
 the integument rests upon a bony surface. 
 
 The erythema, the first degree of radiodermatitis, punctiform and 
 pink at the onset, later on becomes a uniform dusky or purplish 
 red; it gives rise to severe itching, then to desquamation, lasting for 
 a few days to a week, rarely longer. 
 
 The erythema is usually followed by pigmentation which may last 
 for months, varying greatly in different individuals. 
 
 Blebs, scattered, grouped, or confluent upon an erythematous 
 base, may develop after a more energetic exposure and are often the 
 forerunners of ulcers or sloughs. 
 
 Ulceration usually burrows on the floor of a bleb which has 
 suppurated. It is dusky red, smooth or slightly granular, with 
 gently sloping borders, of extremely variable shape and extent, with 
 scanty serous oozing. It is accompanied by burning, tearing, 
 lancinating pains, often of extreme severity, preventing sleep and 
 
454 ARTIFICIAL DERMATITISES 
 
 constituting a serious torment. Radiodermatitic ulcers take a 
 sluggish course, first progressive, then slowly retrogressive; they 
 often last several months or even years. I have pointed out that 
 sometimes they may simulate superficial epitheliomas, biopsy being 
 necessary for a diagnosis. 
 
 Sloughing develops primarily, or under a blister, or around an 
 ulceration. The slough is white, then brown or black, hardly 
 encroaching upon the cutis or on the contrary also involving the 
 cellular tissue, the tendons, the aponeuroses, etc-., briefly, all the 
 subjacent parts. It causes frightful pains, radiating to a distance, 
 of a neuritic character. The course is very slow; demarcation and 
 elimination are long delayed. Relapses, with reproduction of 
 sloughs at the periphery or below are not uncommon. A cure 
 requires months and may be followed by recurrences in situ. A 
 very instructive case of ulcerative radiodermatitis came under my 
 personal observation and was published in the Annates de Derma- 
 tologie, October, 1913. An ulcer on the breast of a young woman, 
 occurring six months after a final .r-ray session, healed in five months; 
 it reappeared spontaneously, without a new radiation, over eleven 
 years afterward and at this time still presented the histological 
 structure of a recent radiodermatitis. It must be concluded that 
 the pathological process persists practically indefinitely. 
 
 The patches of sclerous radiodermatitis which follow upon an ulcer, 
 but may also develop as the sequel of a simple erythema or bleb, 
 have a pathognomonic appearance. There is an indistinctly out- 
 lined spot of white, tense and indurated sclerosis, smooth and 
 interspersed with serpentine or arboreal telangiectases; or there 
 may be an undulating, scaly, lardaceom surface, mottled with pig- 
 mentary spots and purplish macules, adherent and not readily 
 folded; finally, a thickened and deformed genuine cicatrix may be 
 present. These three degrees of lesions may coexist in concentric 
 zones. 
 
 Observers have been impressed with the analogy between the 
 patches of white or lardaceous sclerosis in radiodermatitides and 
 scleroderma in patches, which, however, is more sharply outlined; 
 and also with xeroderma pigmentosum and senile degeneration, but 
 the last-named affections are diffuse and regional (Chapter XVII). 
 
 Complications due to overexposure to the .r-rays should no longer 
 occur at the present day. Before any new application, it must be 
 kept in mind that the patient may forget to mention, or try to 
 conceal a recent .r-ray treatment. Careful inquiries must therefore 
 be made. 
 
 Occupational Radiodermatitides. — Radiologists, unless carefully 
 observant of the most scrupulous precautions, are exposed to a 
 diffuse, insidious, chronic and progressive radiodermatitis, which is 
 
DERMATITIDES DUE TO PHYSICAL CAUSES 455 
 
 always grave and may become fatal. The hands, sometimes the 
 face, are the parts naturally most affected. The fingers at first 
 become cyanotic; the epidermis becomes dry and peels off, the 
 skin becomes swollen and cracked, retracting especially around the 
 nails which likewise become furrowed, split, break and exfoliate. 
 The patient has a constant feeling of constriction. 
 
 The appearance, which is at first suggestive of frostbite or of 
 dysidrosis, later on approximates that of the eczematized prurigos; 
 but the mixture of atrophy, telangiectasis, verrucosities, etc., on 
 the other hand, lends the clinical picture an analogy with xeroderma 
 pigmentosum and with arsenical keratosis. 
 
 The occurrence of epithelioma of the papillary, later the lobu- 
 lated type, is not very rare in these chronic radiodermatitides. 
 It cannot be stated outright that x-rays give rise to cancer, but it 
 must be admitted that their cumulative effect leads to a cutaneous 
 dystrophy on which epithelioma more easily develops in the same 
 sense as on the senile, arsenical, xerodermic dystrophies, or on 
 cicatrices in general. The pioneer radiologists who worked at a 
 time when the remote dangers of the x-rays were still unknown, 
 have nearly all expiated their unwitting lack of caution with severe 
 mutilations and in some instances with their lives. 
 
 Treatment. — This must be primarily prophylactic. The applica- 
 tion of x-rays and radium requires scrupulous attention and con- 
 siderable experience and caution. It must moreover be kept in mind 
 that those cutaneous regions which have once been overexposed 
 retain indefinitely a remarkable vulnerability toward mechanical, 
 physical, chemical and medicinal noxious agents and especially a 
 susceptibility to x-rays; they suggest fire smouldering under the 
 ashes. 
 
 Erythema or blebs are treated like burns. Against the pigmen- 
 tations, hydrogen peroxide or naphthol creams may be employed. 
 Occupational radiodermatitides, sclerotic radiodermatitides and 
 ulcers do well under repeated baths and moist occlusive dressings, 
 notably a chamomile infusion mixed with potash, 1 per 10,000; 
 inunctions with vaselin-lanolin cream and lead-water, or with 
 glycerol of starch. Stimulating, antiseptic, analgesic topical appli- 
 cations and reducing agents in general should be avoided. Oily 
 dressings are often readily tolerated. 
 
 Static baths, high-frequency currents and even heliotherapy 
 have been recommended, but cannot be unconditionally endorsed. 
 In certain cases, the excision of an ulcer may be indicated when 
 this is feasible, or the destruction through superheated air. [Radi- 
 cal surgical excisions of deep x-ray ulcers followed by grafting not 
 only gives prompt relief to the intolerable pains but is the best 
 insurance against the subsequent development of epithelioma.] 
 
456 ARTIFICIAL DERMATITIDES 
 
 Of recent years, especially in America, attempts have been made 
 to treat the spots of keratosis and the incipient epitheliomas of 
 radiologists, through applications of radium. This paradoxical 
 therapy, which has the advantage of being painless, seems to have 
 yielded really successful results. 
 
 TOXIDERMAS. 
 
 The number of substances of all kinds which may damage the 
 skin is so great, their effects are so multiple and variegated that 
 an entire volume might be devoted to this subject without exhaust- 
 ing it. I shall limit myself to a consideration of those features 
 which have the most important practical bearing. 
 
 Etiology. — In the etiology of the toxidermas we have to deal 
 not only with poisons, a group of substances actually incapable of 
 definition, but also with countless medicinal agents, the list of 
 which is extended every day through the achievements of chemistry, 
 as well as many products employed in the industries, in the house- 
 hold, for the care of the person, etc., and finally a certain number of 
 foods and drinks. 
 
 According as the injurious substance has acted through appli- 
 cation or friction on the skin, or by its having been ingested and 
 absorbed, a distinction is made between: External toxidermas, or 
 the direct artificial eruptions of Bazin, on the one hand; and the 
 internal toxidermas, or indirect artificial or pathogenetic eruptions 
 of Bazin on the other. 
 
 In the latter case, the digestive mucosa most frequently serves 
 as the avenue of entrance; exceptionally, the urogenital, respiratory, 
 or even the conjunctival mucosa may be responsible; finally, the 
 injurious substance may have been introduced by the hypodermic 
 route, which is becoming more and more used for therapeutic 
 purposes; eruptions due to sera form an interesting group of this class. 
 
 Symptoms and Diagnosis. — A few general remarks will suffice in 
 this connection. 
 
 Three points have to be settled: (1) The presence of a toxi- 
 derma; (2) its external or internal origin; (3) the discovery of the 
 injurious substances. 
 
 1. As there exists no characteristic sign of toxidenna in general, 
 the prudent physician will make it his rule, when dealing with any 
 dermatoses the diagnosis of which is not at once evident, to think 
 of the possibility of an artificial eruption and to pursue his inquiry 
 in this direction. 
 
 It would be a mistake to assume that the eruption is the 
 entire disease in the toxidermas. Accessory pathological phenomena 
 are frequent. Aside from the painful, burning, tense and espe- 
 
 
TOXIDERMAS 457 
 
 cially itching sensations which usually accompany the eruptions, 
 general disturbances may also be observed, such as malaise, excite- 
 ment, headache, insomnia, various digestive disturbances, a pale 
 or yellowish complexion, etc. Fever may be associated with these 
 symptoms; it is usually moderate and ephemeral; exceptionally it 
 may be very high. 
 
 The internal toxidermas are accompanied in certain cases by 
 enanthema of the buccal, pharyngeal, nasal, conjunctival, genital 
 mucosae, sometimes even by edema of the larynx; this may be not- 
 ably the case in iodism, hydrargyria, etc. It follows from this 
 fact that the differential diagnosis of certain toxidermas from the 
 eruptive fevers or from various infections derived from a mucous 
 membrane, may present very serious difficulties. 
 
 2. The external or internal origin of a toxiderma is sometimes 
 evident at the first glance ; the type of the eruption, its topographical 
 distribution, its localization or generalization may furnish valuable 
 indications in this respect. In other cases, however, this question 
 cannot be settled off hand. It may happen that a substance applied 
 to the skin acts both locally and by absorption. Hence the boun- 
 dary between the external and internal toxidermas is not absolute. 
 
 3. In the determination of the injurious agent, it is essential not 
 to overlook the following considerations: Among the various 
 eruptions which may be caused by the same substances some are 
 specific, plainly characteristic of the cause which has produced 
 them (example: some bromide eruptions, some antipyrinides and 
 arsenical keratosis); others are less characteristic and justify only 
 a presumptive diagnosis (example: iodide acne, bromide acne); 
 still others are commonplace, resulting from the action of many 
 different kinds of substances (example : urticaria) . 
 
 It is a matter of common observation that a given individual 
 reacts to the same substance by an always identical eruption, 
 without a proportion necessarily existing between the dose and 
 the degree of the reaction. Frequently also the same individual 
 reacts by the same eruption toward several different substances. 
 It seems in such cases that the patient makes the eruption, the 
 injurious substance merely playing an accidental determining part 
 which elucidates and reveals, as it were, an existing pathological 
 tendency. Its action has been likened to that of the fingers on the 
 trigger of a loaded gun. It goes without saying that the artificial 
 eruptions which appear under the influence of a variety of causes, 
 are necessarily of an ordinary form. 
 
 Pathogenesis. — The pathogenesis of the toxidermas must be 
 studied from the standpoint of: (1) The conditions under which 
 the injurious action of certain substances is developed; (2) the 
 mechanism of their action. 
 
158 ARTIFICIAL DERMATITIDES 
 
 1. CONDITIONS OF INJURY— The nature-of a substance— its 
 chemical properties — sometimes account for the action which it 
 exerts upon the skin; this is true for the caustic agents, for sub- 
 stances having a strong reducing or oxidizing action, etc. 
 
 In other eases, substances arc concerned which possess special 
 biological properties and under these conditions one must essen- 
 tially remain satisfied with the phrase: Quia est in eis qucedam 
 virtus. . . . The vesicants or rubefacients belong to this group. 
 
 Provided that the conditions of dosage, concentration and dura- 
 tion of action are present, the substances in this first class are 
 sure to affect any human skin, without a predisposition of any 
 kind being required. The resulting dermatitides are external toxi- 
 dermas through direct contact and may be designated as traumatic 
 toxidermas or chemical dermatitides (example: sulphuric acid, croton 
 oil, etc.). 
 
 Other external or internal toxidermas are due to bodies whose 
 chemical character and general biological properties do not explain 
 this influence, which moreover is exerted only in an inconstant, 
 accidental, even exceptional manner, so that one is compelled to 
 attribute the abnormal reaction to conditions of territory, intoler- 
 ance, or individual susceptibility. 
 
 As a matter of fact, there exists no sharp boundary line between 
 the groups of substances acting on all persons alike (example: 
 caustic potash), those acting on many persons (example: carbolic 
 acid), or those acting only exceptionally (example: iodoform). 
 However, in the presence of an inconstant effect, not explained by 
 the conditions of quality, quantity and duration of action, one 
 must necessarily suspect the intervention of a personal factor, a 
 special susceptibility, or a peculiar capacity of reaction. This is 
 what is meant by predisposition. 
 
 Predisposition and Idiosyncrasy. — The question of predisposition 
 to disease, which is connected with that of immunity, has a scope 
 far exceeding the limits of a book of this kind. The problem may 
 be studied from a general point of view in connection with infec- 
 tions, intoxications, nutritional diseases, etc. I have frequently 
 had occasion to allude to predisposition in other chapters, but as 
 it plays the most evident part in the toxidermas, a few lines will 
 here be devoted to its discussion. 
 
 In the first place, it must be emphasized, with Jadassohn, that 
 the term predisposition is applied to two phenomena which up to 
 a certain point are distinct: 
 
 1. Increased sensibility, or hyyersensibility, causing a given indi- 
 vidual to react to a minimum dose, greatly below that which is 
 generally injurious, but the form of the reaction is not unusual. It 
 has been stated that in case of hypersensibility, the question of 
 
TOXIDERMAS 459 
 
 dosage of the injurious agent is of no importance, but this is 
 obviously an exaggeration. 
 
 2. Idiosyncratic intolerance, in which an individual experiences 
 injurious effects from a given substance which it would not produce 
 in any dose on a normal individual. 
 
 It is not always possible to decide which of these phenomena is 
 concerned in a special case; moreover, there exist varieties inter- 
 mediate between these two forms of predisposition. 
 
 In current usage, the word predisposition is employed rather for 
 a sensibility the reasons of which are suggested by a disturbance of 
 the general health ; when the cause of the intolerance is absolutely 
 mysterious, one resorts to Greek and speaks of idiosyncrasy. 
 
 The real nature of so-called predisposition is unknown. Clinical 
 experience teaches that it may be: general, the skin proving sus- 
 ceptible to all irritants; or special, intolerance existing only toward 
 a single substance or group of substances; absolute or relative, 
 namely more or less independent of the dose and the mode of 
 introduction. A medicinal agent is sometimes tolerated when it is 
 ingested or injected, but proves injurious on external application; 
 this is common with mercury and the rule with iodoform, for 
 instance. It is noteworthy that poisons when ingested reach the 
 skin in a lower concentration, especially as the liver retains a 
 considerable share. 
 
 Predisposition is congenital and sometimes even familial, or 
 acquired. It is finally either permanent or temporary and may 
 recur a number of times. 
 
 The causes of the intolerance are generally obscure, frequently 
 multiple and inextricable. 
 
 Often a general disturbance must be held responsible, due to an 
 infectious disease, physical or mental overstrain, a physiological 
 phenomenon such as menstruation, pregnancy, the menopause, etc. 
 A local irritation or infection may invite a toxiderma; seborrhea 
 and acne vulgaris are known to predispose to iodide, bromide and 
 tar acne, just as dental caries and gingivitis provoke mercurial 
 stomatitis. 
 
 Digestive disturbances, preexisting or caused by the toxic agent 
 itself, favor the development of toxidermas; changes in the gastro- 
 intestinal motility, secretions, fermentations, etc., may lead to 
 absorption of abnormal products or to a reaction of these products 
 on the medicinal substance. In the bromide and iodide eruptions, 
 for instance, the role of digestive disturbances seems probable. 
 
 In other cases, hepatic inefficiency or renal insufficiency are held 
 responsible, meaning a diminution in the antitoxic function of the 
 liver or the excretory action of the kidneys; or functional disturb- 
 ances of the cardiovascular apparatus, the nervous system, or the 
 
460 ARTIFICIAL DERMATITIDES 
 
 glands of internal secretion may sensitize the skin or bring about 
 one or another eruptive form and localization. 
 
 Idiosyncratic intolerance may subside in some cases under a 
 gradual and continuous administration, with establishment of 
 habituation or nrithridatization. One may assume that the skin 
 has acquired a greater resistance, or that elimination through the 
 emunctories has improved, or that an immunization has occurred, 
 of which the phenomenon of so-called anti-anaphylaxis is undoubt- 
 edly an example. 
 
 The opposite is noted in respect to certain bodies which are cap- 
 able of accumulation in the organism. Digitalis, bromin, arsenic, 
 chloral and even iodin, etc., are known to belong to this group. 
 However, accumulation accounts only to a very limited degree for 
 idiosyncrasy. 
 
 The usual course of events is as follows: An individual, appar- 
 ently free from anomalies, is attacked, in consequence of the appli- 
 cation or ingestion of some alimentary or medicinal substance, by 
 an eruption of an erythematous, urticarial, eczematous or other 
 type. 
 
 If he has never before absorbed this substance or come in con- 
 tact with it, the case belongs simply to the class of idiosyncratic 
 intolerance. Sometimes, however, he has previously tolerated it 
 without disturbance. In the latter case, whether the toxidermic 
 attack has occurred at the time of one of the disturbances mentioned 
 above or in the absence of a demonstrable adjuvant factor it is 
 almost the rule for this individual to be thereafter, for a fairly long 
 or even indefinite period, hypersensitized to such a degree that the 
 most minute dose of the injurious body, or perhaps of several others, 
 will give rise to a fresh eruptive attack. 
 
 This acquired sensibility has very naturally been interpreted by 
 some as a peculiar instance of anaphylaxis, to which we must devote 
 a few words. 
 
 Anaphylaxis. — Ch. Richet discovered (in 1902) and gave this name 
 to the special sensibility produced by the preliminary injection of 
 certain toxalbumins; it differs from the accumulation of toxic agents 
 in not manifesting itself immediately but only after a certain 
 period of incubation. The conditions under which he observed this 
 phenomenon and the principal facts concerning it are as follows: 
 
 Experimenting on dogs with the poison of actinia [sea-anenomes], 
 Richet demonstrated that an animal injected with a sublethal dose 
 will recover; a new similar dose injected a few days later remains 
 without effect; but if at the end of two to three weeks the same dog 
 is injected with an even ten or twenty times smaller dose, he will 
 suddenly develop very serious or even fatal symptoms. These 
 symptoms, the essential phenomenon of which is a sideration of 
 
TOXIDERMAS 461 
 
 the nervous system with lowering of the arterial pressure, constitute 
 the "anaphylactic shock." Richet assumes that the first injection 
 has stimulated in the blood the formation of a toxogenin, which on 
 contact with a new dose of its antigen combines with it to form a 
 powerful poison, the apotoxin. 
 
 The experiments of Arthus, Theobald Smith and others have 
 shown that this anaphylactogenetic power belongs not only to 
 toxic agents, but that the injection of the blood-serum of an animal 
 into an animal of another species will similarly sensitize it toward 
 this serum. It is now known that in a general way all albuminoid 
 substances will produce anaphylaxis. 
 
 In addition to this direct and "active" anaphylaxis, Richet dis- 
 covered that there exists a "passive" anaphylaxis, in so far as an 
 animal may be sensitized by injecting into it the serum of a sensi- 
 tized animal. I have previously mentioned that the discovery of 
 passive anaphylaxis has been utilized in proving the origin of certain 
 urticarial eruptions, those due for instance to pork or mussels. 
 
 The term anti-anaphylaxis denotes the process by which the 
 outbreak of an anaphylactic shock or crisis is prevented. Credit 
 is due to Besredka for having shown that the preliminary injection 
 of small doses of the determining serum permits the injection of 
 the total dose one hour later without disturbance. A very slowly 
 administered injection is in itself anaphylactic to a certain degree. 
 I have pointed out that a rational attempt has been made to treat 
 urticaria by anti-anaphylaxis. This therapeutic method will per- 
 haps find numerous and important applications in the future. 
 
 That medicinal intolerance and anaphylaxis are not identical is 
 apparent on the following grounds: In the first place, in spite of 
 some contradictory experiments, it has not been established that 
 non-colloid substances may produce an anaphylactic state. 
 Furthermore, it is not uncommon for a toxiderma to manifest 
 itself at the first use of a drug; in these cases, at any rate, there is 
 nothing like the period of incubation which is required for the devel- 
 opment of genuine anaphylaxis. Achard and Flandin were unable 
 to produce in guinea-pigs either an active anaphylaxis with medic- 
 inal agents or a passive anaphylaxis by injecting them with the 
 serum of patients suffering from eruptions due to antipyrin, iodo- 
 form, or quinine. Pending further research, medicinal intolerance 
 must therefore be interpreted as a simple hypersensibility, not 
 partaking of an anaphylactic character. 
 
 It is necessary to point out, however, that Ch. Richet showed in 
 1910 that animals which have been sensitized by an anaphylacto- 
 genetic substance are to a certain degree sensitized at the same time 
 toward all poisons even crystalloids. 
 
 Looking at the question of idiosyncrasy from a wider perspec- 
 
462 ARTIFICIAL DERM AT in DBS 
 
 tive, one may well ask with him if, just as human beings differ in 
 their psychic personality, they are not each endowed with a humoral 
 personality peculiar to the individual; the personal differences in 
 the Immoral make-up, being due to heredity, ingesta, as well as the 
 multiple intoxications and infections which they have experienced 
 in the course of existence, accounting for the differences in the 
 reactions toward injurious factors. 
 
 2. PATHOGENIC MECHANISM— -It is not necessary for the 
 pathogenic mechanism of the toxidermas to be uniform and always 
 identical; it is not even probable that this is the case. 
 
 The interpretation of external toxiderma is not difficult, the 
 condition represents a sort of local chemical traumatism. It must 
 be kept in mind, however, that in order to cause a reaction, the 
 injurious substance must pass through the inert horny layer. The 
 absorption of the normal skin is demonstrable only for volatile 
 substances (ethereal oils, iodin, mercury, etc.), certain fatty sub- 
 stances and the keratolytic substances (salicylic acid). It has 
 been shown, however, that potassium iodide, antipyrin and some 
 alkaloids may penetrate the skin under certain conditions. More- 
 over, the slightest fissure of the horny layer constitutes a portal of 
 entrance. 
 
 Many substances give rise to eruptions when absorbed by the 
 external as well as by the internal route; one is led to assume that 
 the injurious action is exerted as an idiosyncrasy on the constit- 
 uents of the skin itself. It is certainly amazing to see to what 
 degree the cutaneous sensibility must be augmented for a reaction 
 to occur with the infinitesimal quantity of substance carried by the 
 blood stream to a given square centimeter of skin; but one is pre- 
 pared to admit this hypersensibility in view of what has been 
 established in the external toxidermas. 
 
 It is very remarkable that this predisposition is often strictly 
 localized and limited to a given territory which nothing seems to 
 predetermine for this selection; the typical example of the anti- 
 pyrinides, however, compels the recognition of this fact. 
 
 It has been supposed that the vasomotor or trophic (?) nervous 
 system, damaged by the circulating poison, might intervene in the 
 localization of the internal toxidermas, a metameric distribution 
 of which has sometimes been reported. But the inflammatory 
 character of the great majority of toxidermic lesions renders the 
 idea of a purely nervous pathogenic influence rather improbable. 
 
 The role of the blood is indispensable in all not strictly local 
 toxidermas; the injurious agent must be transported either to the 
 nervous elements or to the skin. In a few exceptional cases, the 
 blood medium is even morphologically altered; E. Hoffmann and 
 
TOXIDERMAS FROM EXTERNAL CAUSES 463 
 
 others have noted eosinophilia in hydrargyria and Leredde has 
 demonstrated it in iodism. 
 
 The toxidermas were formerly very simply referred to elimina- 
 tion, or to an attempted elimination of the toxic agent by the cuta- 
 neous tissues. The purifying function thus attributed to the skin 
 is now known to be in reality very limited, if not absent. It has 
 not been demonstrated that in eruptions due to iodides or bromides, 
 for instance, the altered skin contains a larger quantity of the 
 metalloid than the neighboring skin. The positive findings of 
 Adamkiewicz for iodin and of Gutman for bromin are offset by a 
 mass of negative results; Pasini believes that in bromide eruptions 
 the bromin exists in an organic combination not easily demonstrable. 
 As to arsenic, it is known — and the fact has been confirmed by the 
 careful analyses of Arm. Gautier — that the epidermis and its adnexa, 
 hairs and nails, contain a proportion of the toxic agent relatively 
 so high that the epidermic tissues must really be considered as 
 normal routes of elimination of arsenic; but the condition exists 
 both in the presence and absence of cutaneous lesions. 
 
 In certain toxidermas, the part played by microbic infections, 
 especially through pyococci, is very evident. Thus the iodide, 
 bromide and tar acnes, the eruption due to thapsia, the miliaria alba 
 following mercury and the application of plasters, contain staphylo- 
 cocci with such regularity and abundance that the germs may be 
 regarded as practically obligatory collaborators of the toxic agent. 
 
 The eczematous and bullous toxidermas likewise open the door 
 to the same agents which may lead to generalization and per- 
 sistence of an originally toxic eruption, the transportation being 
 facilitated by scratching. 
 
 TOXIDERMAS FROM EXTERNAL CAUSES. 
 
 This section comprises different groups of cases, according as the 
 eruption results from: (A) Badly tolerated medicinal applications, 
 external medicinal eruptions. (B) Application of counter-irritants 
 or caustics, induced dermatitides. (C) Substances used by the 
 patient in his work, occupational dermatitides. (D) Vegetable or 
 animal poisons, dermatitides venenatce. (E) Applications made for 
 the purpose of malingering, simulated dermatitides. 
 
 The morphological appearances assumed by these various toxi- 
 dermas have been sufficiently described in the first portion of 
 this book. They belong especially to the following groups : eryth- 
 emas, urticaria, eczema, pustules, bullae, ulcerations, gangrenes, 
 dyschromias and folliculoses. 
 
 A. External Medicinal Eruptions. — The therapeutic substances 
 which are capable of producing lesions or reactions that the physi- 
 cian had not expected, are innumerable. 
 
464 ARTIFICIAL DERM AT IT IDES 
 
 W'nivr, either pure or containing anodyne products, employed in 
 prolonged baths, in moist dressings, etc., macerates the epidermis, 
 thereby predisposing to pyococcal infections. The phenomenon 
 of the "crop" (poussee), so common in the majority of watering 
 places, is to a large extent referable to the water. Poultices act in 
 the same way, particularly when the linseed has become rancid 
 and therefore irritating. Excessive washing with soap and alkaline 
 or sulphur baths may cause dryness of the skin, redness, desquama- 
 tion and the formation of vesicles. 
 
 The majority of fatty or resinous substances which enter into the 
 composition of plasters are capable, as a result of maceration, of 
 irritating the epidermis and exciting eruptions accompanied by an 
 abundant growth of pyococci. 
 
 , I ntiseptics, even the weakest, such as boric acid, sodium biborate, 
 etc., may prove irritative to the skin. Some remedies of this group 
 are entitled to special mention. 
 
 Pure carbolic acid is a caustic producing a white slough, almost 
 without inflammatory reaction; strong or even weak improperly 
 prepared solutions often give rise to carbolic acid erythema, some- 
 times to vesicle formation with edema, carbolic acid eczema, and 
 even to gangrene when employed in dressings, a fact which must 
 not be overlooked (Chapter XV). 
 
 Tincture of arnica, much liked by the laity for the dressing of 
 contusions, has often a pronounced eczematizing action. 
 
 Formol hardens the epidermis, which cracks and peels off, under 
 simultaneous production of a dermatitis which may be necrotic. 
 
 Salol, a compound of carbolic and salicylic acids, is like its com- 
 ponents frequently the origin of persistent and progressive erythe- 
 mato-vesicular dermatitis. As an admixture in tooth-washes or 
 "catarrh powders," it gives rise to orbicular eczemas of the lips or 
 nostrils which persist indefinitely when not traced to their real 
 cause. 
 
 Iodoform is especially to be dreaded in cases of idiosyncrasy. 
 Following its application in even trifling amounts, the neighboring 
 skin becomes deeply reddened and covered with small confluent 
 vesicles. This dermatitis is accompanied by an erysipeloid or 
 psendo-phlegmonous edema, especially on the face or on the geni- 
 tals; it may even become generalized. The eruption terminates 
 by desiccation or by suppuration; recovery takes place only after 
 two or three weeks. It is certain that iodoform dermatitis 
 results rather from the contact of the iodoform with the epidermis 
 than with the cavity of an ulcer or a wound, or even with the 
 surface of a mucous membrane. 
 
 General symptoms, delirium and even death, have also been 
 observed and are referable to the absorption of this remedy. 
 
TOXIDERMAS FROM EXTERNAL CAUSES 
 
 465 
 
 The substitutes for iodoform, iodol, aristol, europhen, airol, etc., 
 are less frequently injurious. Orthoform may excite an erysipeloid 
 and gangrenous dermatitis. 
 
 Mercury and its salts, in external applications more often than 
 after ingestion or injection, give rise in predisposed persons to 
 eruptions known as cutaneous hydrargyria. It is true that the 
 mechanical factor and the nature of the vehicle also play a role in 
 mercurial inunctions; but the eruption frequently follows upon a 
 simple application of blue ointment (Fig. 1T>) or dressings with 
 sublimate, biniodide, cyanide, mercurial plaster and even applica- 
 tions of calomel. 
 
 Fig. 143. — Cutaneous hydrargyria of eight days' standing, occurring a few hours 
 after inunction of the groins and the axillse with blue ointment for phthiriasis. 
 
 The symptoms consist, in the first degree, of severe reddening 
 with a burning or itching sensation, on which numerous miliary 
 or submiliary vesico-pustules or small purpuric spots appear. This 
 eruption, often localized in the groins, on the genital organs and 
 in the axillse, sometimes tends to become diffuse and then gives the 
 picture of cutaneous hydrargyria due to internal causes. A more 
 30 
 
466 ARTIFICIAL DERMATITIDES 
 
 or less dark and persistent pigmentation often follows the mercurial 
 erythema. 
 
 Reducing agents, so widely employed in dermatotherapy, are 
 all in varying degrees capable of producing dermatitis; this is 
 accounted for by their special chemical effect, sometimes favored 
 by an idiosyncrasy of the patient. Sulphur, sulphites, resorcin and 
 naphthol are usually not injurious unless employed in excessive 
 dosage. Pyrogallol stains the epidermis black; it may produce 
 erythema with enormous swelling and even sloughing. 
 
 Chrysarobvn, when dissolved by the alkaline sweat, gives rise to 
 a brown or purplish, more or less extensive reddening with pruritus 
 and sometimes a pseudo-phlegmonous infiltration lasting several 
 weeks. The bronzed erythema of chrysarobin is typical. When 
 applied near the eyes, the remedy causes a severe conjunctivitis 
 with swelling of the eyelids, ulcerations of the cornea, etc. 
 
 The various tars, notably oil of cade may produce an ordinary 
 erythemato-vesicular dermatitis. Their prolonged employment 
 leads to hyperkeratosis. Some individuals moreover develop an 
 eruption of folliculitis, solid papular elevations centered by a 
 sort of brown comedo, with ultimate suppuration. This tar acne 
 develops especially in hairy regions, particularly on the legs; it is 
 obstinate and lasts several weeks (Fig. 123). 
 
 Oxidizing agents are relatively slightly injurious. However, 
 potassium permanganate in strong solution or as a powder, very 
 strong hydrogen peroxide and other peroxides, alter the horny layer 
 and cause redness and vesiculation. Picric acid, recommended 
 as harmless, is capable of producing erythema with edema and 
 eczematous vesiculation, even when employed strictly according to 
 prescription. 
 
 Dyes for the hair and beard usually have for their basis silver 
 nitrate, subacetate of lead or pyrogallic acid; among their con- 
 stituents, paraphenylene-diamin is especially dangerous. A few 
 hours after the first application, or very often after a period of 
 complete tolerance extending over months and years, an edematous 
 and highly pruritic erythema suddenly makes its appearance on 
 the upper part of the face and especially on the eyelids; rapidly 
 extending to the entire face, the neck and sometimes the shoulders 
 and the hands. If the reaction is severe, the erythema becomes 
 covered with vesicles which rupture and are followed by oozing 
 and crusts. The edema usually subsides in a few days, but the 
 desquamation persists somewhat longer. An acute eczema of the 
 regions indicated above, when the hair or beard has been arti- 
 ficially colored, will be readily traced to its true cause. 
 
 In order to prove that, a particular substance has been injurious, 
 a trace of the suspected substance may be applied on a Aery small 
 
TOXIDERMAS FROM EXTERNAL CAUSES 467 
 
 slightly abraded surface of the patient's skin and covered with 
 gauze and a plaster; from twelve to twenty-four hours afterward 
 an examination will disclose the presence or absence of a dermati- 
 titis. This "reaction test" thus strictly localized is devoid of 
 danger. 
 
 The treatment of the external drug eruptions comprises in the 
 first place the removal of the injurious substance, if traces of it 
 persist. When possible, the employment of this substance and 
 even of analogous products must thereafter be strictly avoided. 
 Next, dressings appropriate to the degree and seat of the lesion 
 may be applied, lotions, sprays, powders, soothing applications, 
 as indicated in the treatment of erythemas, eczemas, etc. 
 
 Internal treatment with calcium salts or ichthyol has sometimes 
 seemed to be of some value in my experience. 
 
 B. Induced Dermatitides. — In this paragraph will be considered 
 the cutaneous irritations and lesions produced intentionally or 
 otherwise by the physician, for therapeutic purposes. Skin lesions 
 voluntarily produced by the patient with a view to malingering 
 will be discussed separately (§E). 
 
 Everyone is familiar with the reactions caused by the customary 
 counter-irritants, rubefacients and vesicants, such as: mustard 
 plaster, hot water, chloroform, spirits of turpentine,, ammonia, 
 ethyl and methyl chlorides, tincture of iodin, iodized and analogous 
 cotton, cantharides plaster or tincture, etc. 
 
 It is noteworthy that their application leaves in some individuals 
 a very undesirable and persistent pigmentation; this excessive or 
 prolonged action may cause sloughs, badly healing ulcers, etc., 
 especially in children and persons with a delicate skin. Old iodin 
 tincture contains hydriodic acid and becomes caustic. The vesico- 
 pustules caused by thapsia, croton oil and tartrate of antimony 
 are often followed by cicatrices, so that these substances should be 
 employed very carefully. 
 
 As soon as the epidermis is damaged there is an open avenue for 
 pyococcic infections and all aseptic precautions must therefore be 
 taken before employing a strong counter-irritant; moreover, clean 
 dressings must be applied after it has done its work. 
 
 Subcutaneous injections of camphorated oil sometimes and 
 injections of paraffin for cosmetic purposes very frequently leave 
 intradermic or hypodermic nodules which have been discussed 
 elsewhere in this book (p. 276). 
 
 C. Occupational Dermatitides. — These comprise a great variety 
 of eruptions ranging from acute erythema, or lichenoid thickening 
 of the skin with cracks, to the different degrees of burns. 
 
 Eczema known as occupational eczema is especially common (Fig. 
 144), and pyodermatitides, in the form of impetigo, folliculitis, 
 lymphangitis, etc., occur. 
 
1 1 is 
 
 ARTIFICIAL DERMATITIDES 
 
 The seat of the occupational eruptions depends upon the region 
 exposed to the injurious contacts. 
 
 The lesions therefore begin preeminently on the hands, more 
 particularly their dorsal surface or still more often in the inter- 
 digital spaces; the nails in the prolonged forms are often worn, 
 detached or grooved, fissured and dotted. Next, the wrists and 
 
 forearms are invaded. The face 
 and neck are affected primarily or 
 secondarily. The covered parts, 
 the scrotum, groins and axillae 
 are damaged in those cases where 
 the clothes are impregnated with 
 irritating dust, gases or fluids. 
 
 The course varies according to 
 the cause, form and degree of the 
 eruption as well as the individual 
 conditions in a given case. Occu- 
 pational eczemas may become per- 
 manently established and recur 
 incessantly, behaving as if the 
 chemical traumatism had been 
 only the determining cause of the 
 onset of a diathetic eczema. 
 
 What has been said about the 
 drug-eruptions permits me to be 
 brief in regard to the eruptions of 
 workers with chemical products 
 (quinin, etc.), photographers (al- 
 kalies and reducing agents, amido- 
 phenol, metol, etc.) and operating 
 surgeons; in the latter, the fre- 
 quent scrubbing and washingwith 
 soap predispose to the injurious 
 action of the various antiseptics. 
 Washerwomen, cooks and dish- 
 
 , . . washers usually have a smooth, 
 
 lie 144.— Occupational eczema 01 ... . K .. .,, , 
 
 washerwomen. sliming, red and parqueted pal- 
 
 mar skin; the excessive employ- 
 ment of potash soap, washing-soda and Javelle water, is here very 
 apt to induce an artificial eczema with a topographical distribution 
 on the hands and fingers, as stated above. 
 
 Bricklayers and plasterers have in the same regions a thickened 
 sometimes fissured epidermis and are subject to eczematization of 
 the fingers, hands and wrists, with pyodermatitis and lymphangitis; 
 the handling of the various cements seems to be the essential cause. 
 
TOXIDERMAS FROM EXTERNAL CAUSES 469 
 
 Grocers handle a mass of irritative substances and sometimes 
 present, especially in the cold season of the year, eczematiform or 
 lichenoid lesions complicated by edema and fissures, which have 
 been designated as 'grocers' itch"; this term is fairly characteristic 
 for the seat and gross appearance of this eruption. 
 
 Cabinet-makers, painters and workmen who use varnishes,, essen- 
 tial oils, especially spirit of turpentine, are exposed to erythemato- 
 vesicular and edematous eruptions bearing a close resemblance to 
 acute eczema or dysidrosis as well as to chronic eczemas. 
 
 Sugar-refiners, confectioners, etc., who are in constant contact 
 with sugar, often suffer from impetigos, whitlows and pyodermati- 
 tides. 
 
 There is finally an entire series of occupations in which the 
 utilized materials themselves or their products give rise to a more 
 or less ordinary dermatitis tending to secondary infections. It 
 suffices to mention in this connection : the acneiform folliculitis, due 
 to tar, petroleum and paraffin; the pyodermatitis of curriers, 
 tanners and knackers; the various eruptions of mechanics, chauf- 
 feurs, etc., who are in contact with impure or rancid oils; the pruritus 
 of bakers [bakers' itch], etc. 
 
 More specific in their cause and manifestations, are the occu- 
 pational eruptions of workers in Provence cane; 1 spinners and 
 weavers of flax; dressers of hemp; sorters or binders of wool; washers 
 of silkworm cocoons; workers with chlorin (chlorin acne); and 
 gardeners (poisonous plants), etc. 
 
 Pigeonneau, or rossignol 2 is an occupational disease of the hands 
 in skin-dyers, which was carefully described by Brocq and Laubry. 
 It is characterized by lenticular ulcerations, not very numerous as 
 a rule, occupying the dorsal surface of the fingers or the hand; they 
 are round or oval, covered with an adherent black imbedded crust; 
 their border is raised and reddened; the ulceration is perpendicular 
 and deep, with an irregular floor. The affection is very painful 
 and heals rather slowly. 
 
 Treatment. — When dealing with an occupational dermatitis, the 
 first thing to be done is to cleanse the parts by means of local 
 baths or moist detergent dressings; these should be more or less 
 frequently renewed and continued throughout the acute stage. 
 In other cases the skin is cleansed with benzin, c6ld cream or vase- 
 lin. It is rarely necessary to resort to chemical neutralization or 
 solvents, which are sometimes dangerous in themselves. Topical 
 medication is governed as usual by the lesion (erythema, burn, 
 eczematization or pyodermatitis) and not by the cause. 
 
 General treatment and especially hygienic rules must not be 
 neglected. 
 
 1 [A reed used for thatch-roofs.] 
 
 2 [Young pigeon and nightingale respectively; popular names for this dermatosis.] 
 
1,11 AkTlPlClAL DEllMATITIDKS 
 
 The difficulty in regard to occupational eruptions consists in 
 the prevention of recurrences. Often, by utilizing precautionary 
 
 measures and cleanliness, with protection of the exposed regions 
 and attention to hygiene, the patient can resume his occupation 
 and avoid the trouble which threatens him more seriously after 
 the first attack. Sometimes, when there is an evident, well- 
 marked and persistent predisposition, a change of employment or 
 occupation becomes imperative. It is readily appreciated that the 
 physician may find himself in a difficult position in cases of this 
 kind. 
 
 D. Dermatitis Venenata. — Numerous indigenous or exotic 
 'plants are capable of producing by contact, not only a transitory 
 urticaria like that caused for instance by nettles, but prolonged 
 eruptions, especially of an erythemato-vesicular or bullous type, 
 with edema, severe itching and sometimes fever. 
 
 The eruption appears soon after the contact; it may extend and 
 become generalized. When the patient's occupation or the data 
 furnished by him do not suggest the cause, one may mistake the 
 etiology of the condition which may thereupon become obstinate 
 and recurrent. A considerable number of seasonal eruptions of 
 the hands and face are of plant origin; this must be kept in mind and 
 inquiries in this direction must be made. 
 
 Among the poisonous plants which are most frequently respons- 
 ible mention may be made of: daphne mezereum, several euphor- 
 bias, rhus toxicodendron (poison ivy) and several related species, 
 primula obconica (primrose), and a few analogous hothouse plants, 
 arnica montana, clematis, colchicum, scilla, thuya, some chrysan- 
 themums, etc. 
 
 There also occurs occupational eruptions of vegetable origin, due 
 to flax, cinchona, vanilla, bitter orange, satin [and other kinds of 
 hard] wood, etc. 
 
 Many animals, of different species, not counting the parasites 
 which will be discussed further on (Chapter XXIV) may give rise 
 to eruptions through contact with them. Such are the medusa?, 
 actinia, processional caterpillars [brown-tail moth], and a few others 
 cantharides, etc. 
 
 Others have a poisonous sting, notably scorpions and many of 
 the hymenoptera — bees, wasps, hornets, bumble-bees, etc. On 
 being stung by one of these insects, an extremely severe pain is 
 immediately felt and is promptly followed by urticarial redness 
 with considerable edema; finally a bullous or vesicular eruption 
 may develop, on the same spot or at a distance. A sting on the 
 tongue or pharynx has been known to cause death. But aside 
 from cases of this kind, alarming symptoms are sometimes observed, 
 cither on account of multiple stings or perhaps due to the effect of 
 
TOXIDERMAS FROM INTERNAL CAUSES 471 
 
 direct penetration of the poison into a vein or to a special sus- 
 ceptibility. The venom of the hymenoptera, studied by Phisalix 
 and by Calmette, is analogous to the venom of serpents. It may 
 cause vertigo, vomiting, respiratory disturbance, weak pulse, fever, 
 cold sweats, syncope and convulsions. Usually the disturbance 
 passes off in a few days. 
 
 The treatment of eruptions due to contact with plants and animals 
 consists in the removal of the cause and in dressing the lesions 
 according to the type of eruption. 
 
 Against the stings of venomous insects may be recommended 
 strong salt water, dilute ammonia, a solution of permanganate and 
 rubbing with various fresh herbs, especially with parsley. In the 
 first place it must be ascertained if the sting has remained in the 
 wound and if this is the case, it must be extracted. Calmette has 
 obtained excellent results from applications of calcium hypochlorite 
 1 to 60 or Javelle water 1 to 100. 
 
 E. Simulated Dermatitides [Feigned Eruptions]. — These are 
 observed among beggars, prisoners, soldiers and in hysterical 
 individuals. Medicinal substances (see induced dermatitides), or 
 poisonous plants, or sometimes burns, are especially utilized by 
 malingerers for the purpose of producing eruptions intended to 
 excite compassion, to avoid a tedious service, or to make the subject 
 interesting. The procedure varies according to the intellectual 
 standard of the individual and his opportunities for securing the 
 necessary materials. 
 
 The lesions extend from a simple discoloration of the epidermis 
 to eczematoid, erysipeloid and pemphigoid eruptions and even 
 sloughing. Their configuration, arrangement and course naturally 
 defy a general description. It is often their bizarre appearance 
 that attracts attention; their angular or geometrical forms are apt 
 to betray their origin; sometimes a trace of the material which has 
 been used is discovered. It should be kept in mind that sycosis 
 is relatively easily induced. 
 
 The seat of the lesions is always accessible to the hand of the 
 patient. Inquiry and investigation frequently fail, the patient 
 keeping up his denial in the face of the unmistakable evidence. 
 Immovable occlusive dressings naturally suppress the pathological 
 manifestations or cause them to shift their place. Unless the 
 patient can be made to see the error of his ways and unless he con- 
 sents to be cured, recurrences are apt to be indefinitely prolonged. 
 
 TOXIDERMAS FROM INTERNAL CAUSES. 
 
 These may be grouped under medicinal toxidermas, serum toxi- 
 dermas, alimentary toxidermas and autotoxic eruptions. 
 
472 ARTIFICIAL DERMATITIDES 
 
 A. Medicinal and Toxic Eruptions of Internal Origin.— It is 
 impossible to make ;i complete list of all medicinal substances and 
 poisons capable of producing eruptions. Some react rather fre- 
 quently upon the skin; with others, tins accessory effect is excep- 
 tional. 
 
 It is not so much the mode of absorption, the dose or the im- 
 purities in the remedy which must he held responsible as it is the 
 idiosyncrasy of the subject. 
 
 The form of the eruption varies not only with the substance but 
 also with the individual. 
 
 I shall restrict myself to a rapid enumeration of the ordinary 
 eruptions and their most common causes and follow with a 
 description of the more characteristic special eruptions. 
 
 Erythema in patches, urticarial erythema and medicamentous 
 roseola represent the most common eruptions. The eruption is 
 situated on the trunk, on the face and on the inner surface of the 
 limbs; it is more or less abundant and extensive; it is sometimes 
 scaly and often very pruritic. It may be accompanied by enanthema, 
 conjunctiva] congestion, erythematous angina, but not by laryngo- 
 tracheo-bronchitis as in measles. Fever and diarrhea are rare. 
 
 The eruption appears at a variable time, often very soon after 
 absorption. It may develop in attacks or extend progressively; 
 it attains its height in two or three days. It is not rare for the 
 patches of a more or less urticarial erythema to spread after the 
 fashion of an oil-spot while the center recovers or heals, resulting in 
 marginate or circinate forms. In a few days, the eruption dis- 
 appears without desquamation and without leaving maculae. 
 
 Toxidermic erythemas are due especially to the following sub- 
 stances: quinin, antipyrine, morphin, the balsams, terpene, chloral, 
 iodides, bromides, digitalis, salicylic, boric and benzoic acids, 
 antimony, arsenic, exalgine, etc. In a soldier who had been exposed 
 to the action of asphyxiating gases, I observed a marginate erup- 
 tion of urticarial erythema, recurring for over eight months. 
 
 Scarlatinoid erythema is less common; it occupies especially the 
 flanks, the great articular folds and may spread over the entire 
 body, persist several days and be associated with a more or less 
 marked and prolonged lamellar desquamation; the clinical picture 
 Mill then be that of a primary acute erythroderma (Chapter VI). 
 Recurrences arc not uncommon. This form is observed especially 
 after the administration of mercurials, quinin, chloral, opium, mix 
 vomica, belladonna, salicylic acid, ipecac, antipyrin, sulfonal, 
 benzoates, etc. 
 
 Urticaria fChapter II), as common as the erythemas with which 
 it is often combined, may be caused by the balsams, quinin, mor- 
 phin, hyoscyamus, antipyrin, arsenic, iodides, bromides, chloral, 
 santonin, etc. 
 
TOXIDERMAS FROM INTERNAL CAUSES 4,'-', 
 
 Purpura is less frequent. A list of drugs which may cause its 
 appearance has already been given (Chapter III). 
 
 Bullous eruptions sometimes result from the absorption of iodides, 
 bromides, antipyrin, arsenic, quinin, salicylic acid, antimony 
 aconite, etc. The appearance is that of a bullous erythema (Fig. 
 146), hydroa, or sometimes Duhring's disease. 
 
 The same substances may give rise to suppurative folliculitides, 
 of acute or sluggish course. 
 
 Strictly speaking, there is no eczema of internal medicinal origin; 
 but an already present eczema may become aggravated by any one 
 of the above-mentioned substances, notably by the iodides, arseni- 
 cals, etc. In case of eczematosis, numerous medicinal agents, and 
 also dietetic errors, etc., are capable of starting an attack. 
 
 Pigmentary spots sometimes originate under the internal use of 
 antipyrin, arsenic, blistering gases and perhaps still other substances. 
 
 Gangrenes, in the form of gangrenous eruptions or gangrene of 
 the extremities, have been observed after absorption of ergot of 
 rye, carbon monoxide, antipyrin, arsenic, iodides and chloral. 
 
 Thallium salts produce a total alopecia. 
 
 Belladonna, morphin, cocain, nux vomica, aconite, etc., may 
 cause pruritus without eruption. 
 
 It is obvious that the cutaneous manifestations due to internal 
 medicaments are varied and often not characteristic; the same 
 drug may produce very different effects. A suspicion of a drug- 
 eruption is created by its behavior, its sudden appearance, its poly- 
 morphism, the absence of symptoms common in the diseases which 
 it simulates and by its recurrence under similar conditions. An 
 inquiry, which must sometimes be most minute and searching, will 
 establish the correctness of the suspicion which has been aroused. 
 Occasionally, if the patient wishes or consents, it is possible to 
 make an experimental demonstration of the diagnosis by adminis- 
 tering a small dose of the supposedly harmful drug. It has been 
 said before (page 461) that it is not possible in these cases to 
 establish a passive anaphylaxis in animals. 
 
 The following eruptions are less common; their characters 
 suffice to suggest their origin; some are actually almost specific. 
 
 Balsamic Erythemas. — Copaiva, cubebs, santal and turpentine 
 give rise to roseolar erythemas or erythematous patches, often 
 urticarial and marginate, very pruritic, of a bright red color, 
 occurring specially on the extensor surface of the large joints or on 
 the upper part of the trunk, later on becoming more or less general- 
 ized. Their frequency has greatly declined since the less common 
 use of the balsams in the treatment of gonorrhea. 
 
 Antipyrinides. — Antipyrin has already been mentioned among 
 the substances capable of exciting various erythemas, urticaria, 
 
474 
 
 ARTIFICIAL i)h:i;\i.\TiT[Di-:s 
 
 purpura, etc. Very rarely, the eruption may simulate syphilitic 
 roseola (A. Fournier), although it lias a slightly deeper shade of red 
 and is less persistent. 
 
 This remedy also produces persistenl erythemato-pigmented 
 patches, which were carefully studied by Brocq and are practically 
 pathognomonic. These patches, single or scanty at the first onset, 
 more numerous when the medication is continued (Fig. 14")), are 
 scattered irregularly and may he situated anywhere; they are 
 round or oval, nummular or the size of the hand, dusky red, well 
 outlined and slightly urticarial and cause a rather pronounced 
 burning sensation. 
 
 
 i 
 
 * 1 
 
 1 lit * * 
 
 *1 
 
 * 
 
 1 
 
 
 If 
 
 It 
 
 FlG. 145. — Antipyrinide. Remarkably profuse eruption of erythemato-pigmented 
 
 spots. 
 
 After a few days the redness subsides and a fine or lammelar 
 desquamation ensues; but the brown or even black pigmentation 
 persists and fades only in the course of time. When the patient 
 takes more antipyrin, after several hours or even in twenty minutes, 
 the same spots again become congested and simultaneously new 
 spots may appear, in haphazard distribution, taking a similar course. 
 They are easily diagnosed from their circumscribed pigmentary 
 and their stationary character. 
 
 Sometimes, a certain number of these spots or patches become 
 the seat of bullcB or vesicles-. 
 
TOXIDERMAS FROM INTERNAL CAUSES 
 
 475 
 
 Cases of localized edema and fulminating gangrene due to anti- 
 pyrin [and affecting the genitals particularly], have also been 
 reported. Compounds containing antipyrin (such as "migrainin," 
 etc.), of course, have the same effects. The erythemas produced by 
 other analgesic and hypotonic agents are not so well known; fairly 
 numerous but dissimilar observations have been recorded. 
 
 Iodides. — Potassium iodide and all other iodides or iodin com- 
 pounds may give rise to diffuse erythemas, urticaria, purpura, or 
 even to gangrene. Nodosities due to the iodides, analogous to those 
 of ervthema nodosum are likewise known to occur. 
 
 Fig. 146. — Iododern 
 
 im of the neck, occurring a day after taking a mixture 
 containing potassium iodide. 
 
 The most typical iodide or potassium-iodide eruption is iodide 
 pemphigus, which has been mentioned before (p. 177) and would be 
 better described, according to its appearance, as bullous (Fig. 146), 
 ecthymatous, or fungoid iodide eruption. When the administration 
 of the remedy is continued, the lesions become ulcero- vegetative, 
 increase in size and often invade the mucous membranes; they are 
 accompanied by general disturbances, diarrhea, albuminuria and 
 cachexia and may cause actual mutilations or death itself. 
 
 Iodide acne is very common and develops almost exclusively in 
 kerotic individuals; it affects the same areas as acne vulgaris, 
 
176 ARTIFICIAL DERMATITIDES 
 
 from which it differs only in the more inflammatory character and 
 the greater size of the papulo-pustules, their dark red color and their 
 deep induration. Sonic lesions may be distinctly anthracoid 
 ! iododerma tuberosum I. 
 
 Bromides. The most specific eruptions are produced by potas- 
 sium bromide, more frequently than by other bromin compounds 
 usually after the large and prolonged doses prescribed, for instance, 
 in epilepsy. 
 
 Bromide acne is like iodide acne; the ecthymatous and fungoid 
 bromide eruptions resemble iodide eruptions of the same type. 
 
 Fungoid papulo-tubercular bromide eruptions are less common. 
 but are pathognomonic (bromoderma tuberosum). It consists of a 
 nummular or more extensive prominence, with a crusted mammil- 
 lated or papillomatous surface, of a purplish red color and peculiarly 
 soft quality, giving the sensation of wet velvet to the touch. The 
 distinctly outlined patch is bordered by a margin of sub-epidermic 
 suppuration; it enlarges by several millimeters daily and becomes 
 confluent with neighboring lesions. The fungoid bromide eruptions 
 occur chiefly on the face and especially the nose though often on 
 the legs (most frequently in my experience] or the buttocks, but they 
 may also be met with in other regions. 
 
 Their softness and rapid course distinguish them from papillo- 
 matous or fungoid tuberculosis, fungoid syphilides and pemphigus 
 vegetans. Pasini interprets the cutaneous lesions as due to bromin 
 liberated in the stomach under the influence of hypochlorhydria. 
 
 Hydrargyria. — Mercury and all its compounds without exception, 
 whether absorbed by the gastric route, inhaled in form of mercurial 
 vapors, injected into the mucous cavities, veins or subcutaneous 
 tissues, may occasion an attack of cutaneous hydrargyria; infinitely 
 small doses sufficing in the presence of a special idiosyncrasy. 
 Hydrargyria through external applications is relatively frequent; 
 through ingestion or injection it is very rare in proportion to the 
 large number of patients to whom mercury is administered. It is 
 advisable, however, to keep this possibility in mind. 
 
 Alley and Bazin have described three degrees of hydrargyria: 
 
 In the benign forms the trouble is limited to a localized redness 
 with a few small vesicles, especially in the groins and on the inner 
 surface of the thighs. 
 
 In the moderate form, there is a severe erythema occupying the 
 large folds, the groins, the axillae as well as the palmar and plantar 
 regions; the red surface, sometimes dotted with hemorrhagic points, 
 becomes covered with an abundant crop of small vesicopustules 
 resembling miliaria alba. There is an intolerable itching and burn- 
 ing sensation; fever, digestive disturbances and albuminuria may 
 be present. The crusts are followed by oozing, then by a more or 
 
TOXIDERMAS FROM INTERNAL CAUSES 477 
 
 less persistent lamellar desquamation (see Fig. 143). The clinical 
 picture may be exactly that of an acute or subacute primary erythro- 
 derma; upon occurrence of this eruption, hydrargyria should 
 always be suspected. 
 
 The malignant form is accompanied by swelling of the face and 
 the extremities, by large bullae, pyodermatitides, abscesses, adenitis, 
 angina and gangrene and may lead to death. Desquamation occurs 
 in large shreds. It is noteworthy that in cases of cutaneous hydrar- 
 gyria, mercurial stomatitis, colitis, etc., are not infrequently absent. 
 
 Arsenic. — Aside from the ulcerations of the skin and mucous 
 membranes observed in occupational arsenic poisoning, the adminis- 
 tration of arsenic as a remedy gives rise especially in the palmar and 
 plantar regions, but also elsewhere, to erythemas, urticaria, purpura, 
 bullae, etc. The frequency of zona in patients who take arsenic has 
 been noted. Injections of the arsenobenzols are followed, in rare 
 instances, by more or less generalized eruptions of erythematous 
 spots; even scarlatiniform erythemas have been reported. 
 
 Pigmentations, in spots or diffuse, as well as arsenical keratoses 
 are more typical; I have seen the latter, associated with a dystrophic 
 condition closely suggesting xeroderma pigmentosum or senile 
 degeneration, give rise to multiple epitheliomas, the so-called arsenical 
 cancer. 
 
 Treatment. — In the presence of a medicinal toxiderma of any 
 kind, the essential point is the discovery of the injurious substance 
 and the avoidance of its use. When its employment is absolutely 
 required [as with arsenobenzol in syphilis] it should only be after a 
 long interval, beginning cautiously with small doses, and [if possible] 
 varying the form and mode of administration of the remedial agent. 
 Rest, a laxative, abundant drinks, especially milk mixed with 
 Vichy or Vals water and large enemas, may prove useful. 
 
 Some medicinal eruptions (bromides, arsenic, mercury) persist a 
 really long time after the responsible medication has been stopped 
 and one must be prepared for this. The employment of corrective 
 compounds or of so-called antidotes is not to be recommended. 
 The cutaneous lesions should be treated [symptomatically] accord- 
 ing to the form of the eruption. Against the general symptoms of 
 iodism, Milian has recently recommended adrenalin. 
 
 B. Serum Eruptions. — The disturbances which have been 
 observed since the therapeutic employment of antitoxic sera 
 (antidiphtheritic, antitetanic, antimeningococcic sera) were first 
 attributed to the antitoxins, but are now known to be due to the 
 vehicle, usually horse serum and may be produced by any foreign 
 serum. The contributions of Arthus and von Pirquet, the clinical 
 studies of Marfan, Weil-Halle and Lemaire, among others, have 
 helped to elucidate the relations existing between "serum sickness" 
 and anaphylaxis, 
 
178 ARTIFICIAL DEItM ATI TIDES 
 
 True scrum symptoms, namely those occurring after the first 
 injection, arc rather rare, being observed in only 14 per cent, of the 
 ease-, according to L. Martin. They may appear very soon, or more 
 frequently after an incubation of ten to fifteen days and generally 
 consist of urticaria or a marginate ephemeral erythema, preferably 
 localized in the vicinity of the injection, or disseminated. 
 
 When another injection of serum is administered a long time (at 
 least fifteen days, but even several years) after the first, the onset of 
 anaphylactic symptoms is frequently seen (in 50 per cent, of the 
 cases), developing either immediately or after four or five hours or 
 sometimes after two to ten days. 
 
 The symptoms developing promptly consist of anxiety, dyspnea, 
 weak pulse and vomiting; they are controlled by injections of 
 adrenalin. 
 
 The more delayed disturbances manifest themselves under two 
 type-, which are often associated: 
 
 1. A local reaction, an erysipeloid or pseudo-phlegmonous redness 
 with glandular swelling, lasting from two to four days. Marfan calls 
 this the " Arthus phenomenon." 
 
 2. A general reaction, a more or less profuse eruption of urticaria, 
 with swelling of the face, or a marginate erythema with extensive 
 policy clic patches, accompanied by edema, sometimes by anemia, 
 subieterus, purpura, general prostration, very painful arthralgias 
 and a fever up to 38° or 39° C. [101°-102° F.], lasting twenty-four 
 or forty-eight hours. These clinical symptoms are associated with 
 somewhat variable hematological disturbances; leukopenia or 
 leukocytosis, mononucleosis, presence of precipitins, sometimes of 
 hemolysins, delayed coagulation, etc. 
 
 In order to avoid as far as possible the necessity for repeated 
 injections in the course of a disease which requires serotherapeutic 
 treatment, it is advisable to employ the scrum freely and repeatedly 
 within the first few days. But the fear of serum accidents should 
 in no case cause the abandonment of a re-injection when this is 
 demanded by the nature and course of the infection; this at least 
 is the rule laid down by the most competent authorities. 
 
 All efforts should be made to avoid and control these symptoms. 
 The best precaution consists in administering the re-injection 
 very slowly, carefully watching the patient. Except in extremely 
 urgent cases, it is even preferable to employ successive injec- 
 tions with small doses according to Besredka's method. Begin 
 by slowly injecting 1 c.C. of serum under the skin; one hour later, 
 inject 2 c.C.; finally, after another interval, the total amount of the 
 dose is injected. Calcium chloride, in daily doses of 1 to .'! grams, 
 also possesses, as shown by Netter, a distinct preventive action; it 
 diminishes by three-fourths the number of eruption cases among 
 
TOXIDERMAS FROM INTERNAL CAUSES 479 
 
 re-injected patients and has besides a curative value. Flandin, 
 Martin and Darre, etc., have experimentally studied the serotherapy 
 of serum symptoms endeavoring to produce an immunization by 
 means of repeated injections of very minute doses, constituting a 
 curative anti-anaphylaxis. Their results are inconstant. 
 
 C. Alimentary Eruptions. — In the case of an eruption occurring 
 after the ingestion of a given food or drink, it is often very difficult to 
 ascertain how far the symptoms are referable to the real toxicity 
 of the suspected substance, the idiosyncrasy of the patient, or the 
 auto-intoxications revealed on this occasion. 
 
 Any food or drink the ingestion of which is usually forbidden to 
 persons suffering from urticaria, pruritus and eczema, for instance, 
 may accidentally give rise to an acute eruption or increase a pre- 
 existing dermatosis in predisposed individuals. (See Therapeutic 
 notes, §12.) 
 
 The following may be considered as toxic, that is injurious, for 
 most people: spoiled meats or fish, especially pork; very high 
 game; certain meat extracts; spoiled or diseased mussels; edible 
 mushrooms which have begun to putrefy, etc. 
 
 The eruption usually follows closely on the ingestion and lasts a 
 very variable time. It consists of urticaria of all kinds, urticarial, 
 scarlatinoid or polymorphous erythema, purpura and bullae. 
 
 General disturbances, more or less pronounced or serious, are its 
 usual accompaniments in the form of fever, vomiting, choleriform 
 diarrhea and various nervous disturbances. 
 
 The treatment must aim primarily at emptying the digestive 
 tract through all means at our command. 
 
 The patient must then be placed on a strict diet, or better a milk 
 diet, for some time to come. The nervous symptoms are counter- 
 acted by symptomatic treatment and the same applies also to the 
 cutaneous manifestations. 
 
 D. Autotoxic Eruptions. — Although these are not artificial erup- 
 tions, they may be considered as toxidermas and accordingly may 
 be discussed in this chapter. 
 
 At the present day, a general description of the cutaneous mani- 
 festations of arthritism would be out of date; although some authors 
 try to substitute chronic auto-intoxication for the vague term 
 diathesis implied in this concept, the so-called arthritides of Bazin 
 are now only of historical interest. 
 
 It is equally impracticable to draw a picture of the cutaneous 
 manifestations of gout, uremia or urinary insufficiency, hepatic 
 insufficiency, cholemia, the gastro-intestinal dyspepsias, etc.; an 
 attempt of this kind would be blocked by too much that is unknown. 
 In discussing the erythemas, urticarias, purpuras, eczemas, lichens, 
 pruritus and prurigos, acnes, etc., what little is known of the relation 
 
180 ARTIFICIAL DERMATITIDES 
 
 of these dermatoses to general nutritional disturbances lias been 
 mentioned. I repeat that eczematosis of adult or aged individuals 
 may not infrequently lead to the discovery of a still latent internal 
 cancer, an existing pyelonephritis or nephritis, etc. 
 
 It is only the eruptions of diabetics, the so-called "diabetides" 
 of A. Fournier, that admit of a more or less general review. 
 
 Diabetic Eruptions. These are of two kinds: Some might he 
 considered as internal toxidermas, dependent solely on the altered 
 organic environment; these include pruritus, chronic urticaria, 
 eczema, purpura, gangrenes and xanthoma. Others require in 
 addition the intervention of an external factor, such as the pyococcic 
 infection in the case of impetigo, ecthyma, folliculitis, furuncles or 
 carbuncle; irritation through the sugar in the urine, in the case of 
 genital diabetides. The latter alone require discussion. They may 
 constitute the first symptom to arouse attention and lead to the 
 diagnosis of glycosuria. In the absence of the necessary cleanliness, 
 especially in women, the sugar-containing urine on soiling the skin 
 irritates the epidermis and creates an excellent culture-medium for 
 the yeasts and the microbes of suppuration. These women will 
 accordingly develop pruritus, chronic erythema, or an often very 
 red, edematous and oozing eczema, with sharp sinuous outlines, 
 marked by a raised horny border or a crop of pustules, with an 
 acute, obstinate or relapsing course. This diabetic eczema of the 
 vulva often extends to the thighs, the perineum, the groins and the 
 abdomen. In diabetic men, the glans and especially the prepuce 
 are often red, swollen, chapped and eroded; the preputial orifice 
 finally presents a fibrous induration, with retraction and radiating 
 fissures, or even with complete phimosis. These various lesions 
 sometimes reveal the presence of diabetes mellitus. 
 
 In both sexes the clinical picture may become complicated by 
 erysipelas or gangrene. 
 
 The treatment must aim at diminishing the glycosuria through 
 diet, hygiene and if necessary by means of antipyrine or its ana- 
 logues. Absolute cleanliness must be maintained; with frequent 
 application of alkaline, weakly antiseptic or astringent lotions 
 and bland powders. Painting with a 1 per cent, solution of silver 
 nitrate is often useful. Circumcision should be avoided if it be 
 possible, for it is not devoid of danger in these conditions. A " cure" 
 at the Vichy [or other alkaline] springs is indicated. 
 
CHAPTER XXIV. 
 NEURODERMATOSES; PRURITUS AND PRURIGO. 
 
 Pruritus, or itching, is a peculiar sensation which induces scratch- 
 ing; it is as incapable of definition as is a gustatory or a tactile 
 sensation. It is irrelevant whether this sensation, in different cases, 
 be compared to prickling, tickling, tingling, the crawling of an 
 insect, etc.; the word itching includes all these varieties and is 
 understood by everybody. 
 
 The finer pathogenesis of pruritus is entirely obscure. In order to 
 interpret the dissociations of sensibility observed in certain diseases, 
 physiologists have been led to suspect the existence of special organs, 
 nerves or nerve-terminals, for the different forms of sensibility, some 
 of which manifest themselves only on the skin and on the neighbor- 
 ing mucous membranes: touch, pressure, pain, heat and cold. It 
 has been surmised that this may be true of pruritus also, but neither 
 anatomy nor experimentation has confirmed this theory. 
 
 In all probability this mode of sensation is dependent on the 
 ordinary sensory nerves, although it has been attributed by Jacquet 
 to the sympathetic nerves. 
 
 Itching results in different cases either from a special property of 
 the irritant: artificial pruritus ; or from cutaneous lesions of various 
 kinds: secondary pruritus; or from a special tendency of the indi- 
 vidual, sometimes occasioned by local factors: primary pruritus. 
 Frequently several of these conditions exist in combination. 
 
 The practically inevitable consequence of itching is scratching. 
 When the latter leaves the skin intact or produces only very ordinary 
 traumatic lesions, even when more or less complicated by secondary 
 infections, the existing dermatosis is described as pruritus, adding 
 to this term some qualification suggestive of the pathogenesis or 
 clinical variety of the pruritus. However, when the scratching 
 gives rise to certain special reactions in the skin (papules of stroph- 
 ulus, of prurigo, or lichenization), the dermatosis receives the name 
 of prurigo, of which also several varieties are recognized. 
 
 The distinction between pruritus and prurigo rests accordingly, 
 in my opinion, upon a morphological and directly demonstrable 
 fact, namely the presence or absence of the peculiar papules which 
 I have previously discussed (Chapter VII) or of lichenization. It is 
 really of small importance, for it is not uncommon to find a pruritus 
 becoming transformed into a prurigo after a certain time. 
 31 
 
482 NEURODERMATOSES— PRURITUS AND PRURIGO 
 
 Under the special name of neurodermatoses are grouped pruritus 
 and the prurigos which are neither artificial nor secondary, in which 
 the itching appears as if primary and essential; it is dependent on 
 a nervous disturbance of unknown character directly causative of 
 the cutaneous manifestations. 
 
 Artificial Pruritus. — It is a matter of common knowledge that 
 certain irritants of the skin possess pruritic properties in them- 
 selves. The crawling on the skin or the bites of parasites such as 
 lice, bed-bugs, fleas, itch mites, oxyuris, the stings of the hairs of 
 mttles or of the processional caterpillar, the application of a large 
 number of substances of vegetable, animal or chemical origin give 
 rise to more or less itching in all individuals. 
 
 It may therefore be stated, with llebra, that under these con- 
 ditions, pruritus is physiological. 
 
 Scratching in such cases may be really useful, being a defensive 
 movement which may be reflex and sometimes unconscious, whose 
 aim is the removal of the injurious agent. 
 
 Uncleanliness or, on the contrary, the excessive use of soap, etc., 
 may also be the cause of persistent itching. 
 
 The severity and duration of artificial pruritus are governed by a 
 personal coefficient; it varies with the age of the patient, his tem- 
 perament, his physical and reactionary state, his hygienic habits and 
 the possible existence of a faulty diathesis. It can be modified, 
 moreover, by suggestion or autosuggestion; many people feel like 
 scratching as soon as the conversation turns on lice or bugs. It 
 may assume the proportions of an obsession, a neurosis or mania — 
 a condition which is designated under the name of parasitophobia, 
 acarophobia, or dermatophobia. Inversely, it is at least modified by 
 habituation, intercurrent fibrile diseases, etc. 
 
 Secondary Pruritus.— Many dermatoses of external or internal 
 origin include pruritus among their usual or possible symptoms. 
 
 When the pruritus accompanies or follows the eruption, the inter- 
 pretation of the fact is relatively simple. 
 
 It may, however, precede it. In such cases, the question arises 
 if the pre-eruptive pruritus is the effect of not yet perceptible his- 
 tological lesions, or if it is a concomitant or preliminary effect of the 
 cause which is about to give rise to the eruption, or finally if it is not 
 itself the cause of this eruption by the scratching which it causes; 
 in other words, if it is not a primary pruritus. 
 
 The solution of this question in the different cases which may 
 present themselves, constitutes one of the principal difficulties of the 
 pruritus and prurigo problem. 
 
 There would be no advantage in dwelling at length on pruritus 
 in the dermatoses; this symptom, with its peculiarities, has been 
 pointed out in each skin affection separately. The most pruritic 
 
PRIMARY PRURITUS 483 
 
 of these diseases are scabies, urticaria, eczema, certain medicinal 
 eruptions, lichen planus, Duhring's disease, certain erythrodermas, 
 some leukemias and mycosis fungoides. 
 
 As the result of scratching in the pruritic dermatoses the lesions 
 of lichenization may appear and one may speak therefore of secondary 
 prurigo. 
 
 On the contrary, many cutaneous affections practically never 
 give rise to itching, notably the syphilides, psoriasis, lupus, leprosy, 
 tumors, etc. 
 
 PRIMARY PRURITUS. 
 
 This designation is applied to pruritus which is not connected 
 with an external and evident cause. The skin is healthy, but, 
 nevertheless, there is itching, sometimes to an intolerable degree. 
 Strictly speaking, this pruritus should not figure among the derma- 
 toses; but although the seat of the disease is elsewhere, the derma- 
 tologist's advice is invariably sought because the symptom resides 
 in the skin. 
 
 This primary pruritus may be diffuse and even generalized, or 
 it may be localized; the fact must be emphasized from the start 
 that an internal and general cause may manifest itself by a regional 
 or partial disturbance. 
 
 Pathogenesis. — The pathogenesis of primary pruritus, also known 
 as essential pruritus or pruritus from internal causes, has long 
 taxed the ingenuity of physicians. Anticipating the data of posi- 
 tive knowledge, it has been assumed to depend sometimes on 
 a systemic disorder through intoxication, auto-intoxication or 
 nutritional disturbance: dyscratic pruritus; in other cases, on a 
 nervous disturbance or even on a neurosis: nervous pruritus. 
 The distinction between these two pathogenic mechanisms is some- 
 times not easily made and rests, moreover, merely on hypotheses. 
 
 Auto-intoxication actually seems to be involved in the pruritus 
 of icterus, diabetes, uremia and dyspepsias, which have their coun- 
 terparts in the toxic pruritus due to morphin, belladonna, caff em- 
 poisoning, botulism, etc. However, in order to produce pruritus, 
 the action of the poison must necessarily affect some part of the 
 nervous system-, terminal or central; making use of a bold figure 
 of speech, it has even been said that it is the convolutions of his 
 brain which the patient scratches on the skin. Hence, although 
 of toxic origin, this dyscratic pruritus would be nervous in its 
 mechanism. 
 
 On the other hand, it is an extremely obvious fact that a pruritus 
 may result from a nervous perturbation, the proof is furnished by 
 emotional pruritus, irritative pruritus, the pruritus of tabes, that of 
 certain classified neuroses, such as neurasthenia, chorea, etc. 
 
484 NEURODERMATOSES— PRURITUS AND PRURIGO 
 
 The statement has even been made that a pruritus not referable 
 to an external cause or to an exogenic or endogenic toxic factor 
 might be considered as an autonomous neurosis, an idea which is 
 expressed in the term of neuroderma, introduced by Brocq. 
 
 By Jacquet, who made a specialty of the study of the sensory 
 disturbances of the skin, pruritus was interpreted merely as the 
 exaggeration of the normal cutaneous sensations; in the physio- 
 logical condition, the total sensations coming from the integument 
 constitute a harmonious whole, which may be called euderma; 
 when this balance is disturbed, for example, under the influence of 
 cerebral strain, or the absorption of certain foods, pruritus makes 
 its appearance. 
 
 Etiology. — The causes of primary pruritus are infinitely variable 
 and of different kinds. As general and predisposing causes may be 
 mentioned the race, the geographical and social environment (J. C. 
 White says that in the United States pruritus is a national disease; 
 in European countries the Jews pay a heavy toll) ; a nervous or 
 arthritic heredity, resulting from a bad hygiene of overnourished, 
 gouty, diabetic, etc., progenitors; and the age of greatest activity, 
 which is from twenty to forty years, in both sexes. 
 
 The following conditions act as favoring or determining factors: 
 Brain-fag, which is Aery common in large cities; worry; late hours; 
 grief; venereal excesses; cold and heat, some forms being seasonal; 
 Duhring described a pruritus hiemalis (winter pruritus) which is 
 often a prurigo; Bazin reported a pruritus a colore in persons 
 employed in the vicinity of fires; — and hygrometric and barometric 
 variations, to which some pruritics are susceptible. 
 
 To the same group of causes belong the following: Dietetic 
 errors, overeating, abuse of meats, condiments, stimulating bever- 
 ages, such as coffee, tea, alcoholic drinks, etc.; a bad condition of 
 the teeth and gums, also habitual constipation, which act as intoxi- 
 cations; and the employment of certain remedies which cause a 
 toxic pruritus, for example, belladonna, caffein, arsenic, morphin, 
 opium, cocain, etc. 
 
 Diathetic or dyscratic pruritus is often referable to auto-intoxi- 
 cations, nutritional disturbances, functional disturbances or organic 
 lesions of the viscera, the following being represented in this etiology : 
 diabetes, gout, obesity, hepatism — with or without cholemia and 
 often out of proportion to the degree of icterus, but perhaps related 
 to the cholesterinemia, major and minor uremia, pyelonephritis, 
 chronic enteritis, chronic appendicitis, circulatory disturbances, 
 cancer, tuberculosis, the leukemias, etc. 
 
 The nervous disturbances accompanied by pruritus are less 
 frequently those of organic origin like hemiplegia, brain tumors, 
 general paralysis and tabes (Milian) than those of functional 
 
PRIMARY PRURITUS 485 
 
 character. Nervous pruritus is commonly observed among social 
 failures, unhappy inventors, mental defectives, as the result of too 
 much work or too much play and as the sequel of an emotional 
 disturbance; the original depression is aggravated by the con- 
 stantly recurring distress and by insomnia, leading to neurasthenia, 
 melancholia and sometimes suicide. Formerly, cases of pruritus 
 connected with pregnancy, menstrual disturbances, utero-ovarian, 
 prostatic or vesical diseases, were interpreted as reflex pruritus, 
 but these are now referred rather to auto-intoxications. 
 
 Hematogenic pruritus is observed, although inconstantly, in the 
 leukemias and may lead to the recognition of the blood disease. 
 
 Determining causes are those which may excite a latent pruritus 
 and bring on a crisis. The time of disrobing at night is very com- 
 monly dreaded by pruritic patients, as it becomes the occasion of 
 a real paroxysm; it is impossible to say if the exposure to cold, 
 contact with the air or decompression are responsible; at any rate, 
 many healthy persons scratch when disrobing, notably the majority 
 of women after having removed their corsets, belts or garters. 
 
 The attacks may also be brought on by a bath, rapid walking, 
 cold or heat, even by a perfectly harmless meal. Certain persons 
 are attacked by pruritus immediately after the ingestion of some 
 food or drink, before any actual absorption can have taken place 
 as if under the effect of a reflex; as particularly harmful in this 
 respect are mentioned acid fruits, mussels and shellfish, cheeses, 
 spices, alcoholic beverages, tea, coffee, etc. 
 
 Often, however, the attacks occur spontaneously, even during 
 sleep, apparently resulting from a nervous discharge. 
 
 A few general data, well elucidated by Jacquet, dominate the 
 etiology of pruritus: 
 
 1. Predisposing and determining causes, internal and external, 
 are often associated and act through a cumulative effect constitut- 
 ing the prurigenetic summation. 
 
 2. A preceding pruritus invites another; apparently each organic 
 cell stores up more or less the stimulation which it has undergone, 
 through a kind of local memory; this is prurigenetic mnemoderma. 
 
 3. The accumulated sensory energy may become stationary or 
 it may, on the contrary, become transported and transformed, 
 representing sensory metastasis. 
 
 Symptoms. — Pruritus, being an essentially subjective phenome- 
 non, manifests itself only by scratching. Just as there are all 
 possible degrees of itching, from a slight distress, which is easily 
 forgotten, to an imperious, inexorable necessity, against which no 
 provision holds out, so there are likewise all sorts and forms of 
 scratching. An insignificant pruritus yields to simple rubbing with 
 the finger-tip; a severe attack requires forcible scratching with the 
 
486 NEURODERMA TOSES— PRURITUS AND PRURIGO 
 
 nails <>r rubbing with a rough towel, a brush or some other instru- 
 ment which the patient uses as a curry-comb; sometimes a cold or 
 hot application may accomplish the same object. 
 
 No relation, however, can be established between the severity 
 of the pruritus and the scratching, which is modified by individual 
 factors or conditions inherent to the disease. 
 
 Whoever has witnessed a characteristic pruritic crisis will retain 
 a lasting impression. At the onset, the patient endeavors to con- 
 trol himself; gradually he yields to the need of scratching, which 
 incessantly increases, its satisfaction being accompanied by a 
 truly voluptuous sensation; all restraint is promptly lost; pale, 
 anxious, distracted by his trouble, the patient furiously excoriates 
 himself, mutilating his skin and literally torturing himself, as if 
 in the power of a blind force. Sometimes it is not until the skin 
 is raw and streams with blood that relaxation occurs, satisfaction 
 is obtained and the attack is over. The patient remains exhausted 
 and as if ashamed of himself. Comparison with an epileptic attack 
 and that involved in the term of "cutaneous masturbation" is 
 entirely justified. 
 
 It is impossible to say why scratching, even when carried to such 
 an excess, produces relief; but all pruritic patients declare that the 
 burning pain of the excoriations is preferable to the annoyance of 
 the itching. 
 
 The attacks usually last from five to fifteen minutes, sometimes 
 an hour or longer; there is no rule as to their frequency and the 
 rhythm of their recurrence. 
 
 The pruritus described above may be diffuse and even general- 
 ized; it is more frequently partial, regional, localized on a more or 
 less extensive portion of the integument. But a diffuse pruritus 
 sometimes tends to become localized after a certain time or.inversely, 
 a regional pruritus may be seen later on to radiate and become 
 diffuse. 
 
 It is a noteworthy fact that a localized pruritus, originating under 
 the influence of a local cause, may recur in situ on the occasion of 
 an internal or general cause, through the effort of the mnemoderma 
 referred to above; in this way an anal pruritus, for instance, caused 
 by oxyuris or hemorrhoids, w r ill recur at the time of dietetic errors 
 or overexertion. 
 
 The consequences of scratching are partly immediate and partly 
 remote. The traumatism produces in the first place congestion, 
 with local heat and more or less interstitial exudation, that is, 
 simple or urticarial erythema. 
 
 I believe that by itself alone it may also excite an eczematous 
 reaction, traumatic eczema (Chapter IV). 
 
PRIMARY PRURITUS 1X7 
 
 More forcible scratching causes linear excoriations, usually 
 directed in the course of the nails, which suggests their origin in 
 spite of denial on the patient's part. Often the excoriations are 
 punctiform and occupy follicular prominences, because from the 
 beginning of the irritation the congested follicles have been raised by 
 a spasm of their erector muscles and have projected above the gen- 
 eral level. These excoriated follicular papules, covered with a bloody 
 or serous crust, must not be confused with the papules of prurigo. 
 
 The remote effects of scratching are in part of a special kind, 
 consisting of papulation or lichenization and suffice to place a given 
 case of pruritus in the group of the prurigos. 
 
 Others are of an ordinary kind, namely secondary infection by 
 pyococci, through the avenue of the traumatism giving rise to the 
 most varied pyodermatitides. Even in the absence of suppura- 
 tion, chronic scratching causes hypertrophy of the concatenated 
 glands. Pigmentation, more or less diffuse, is likewise common. 
 The worn-off nails which become polished and shining, have been 
 mentioned elsewhere (Fig. 138). 
 
 It will be seen, with Jadassohn, that from the standpoint of the 
 effects of scratching, the pruritic diseases may be divided into 
 two classes: in the first, the patient's nails tear off everything that 
 protrudes and even dig into the epidermis to tear off shreds of 
 tissue; this biopsic pruritus, as it was called by Besnier, is observed 
 in scabies, pediculosis, sometimes in diabetes, Duhring's disease 
 and the prurigo of Hebra. Pyodermatitides are commonly present 
 in these cases. 
 
 The second form of pruritus, although sufficient to cause insom- 
 nia, is relieved by friction, pressure, etc., and is unaccompanied by 
 any traces of scratching. Senile pruritus, the pruritus of lichen 
 planus, of some types of icterus, of urticaria and of phthiriasis, belong 
 to this group. The reasons for this difference are unknown. 
 
 Clinical Forms. — It is not easy to formulate a picture of the 
 forms of pruritus according to their origin. The following general 
 remarks may be made on this subject. 
 
 Dyscratic pruritus, that of diabetes and icterus in particular, 
 is often generalized, is observed in relatively aged individuals, is 
 especially nocturnal and gives rise to deep multiple excoriations. 
 
 Nervous pruritus, or neuroderma of Brocq, attacks youthful or 
 adult persons, is often regional or partial, occupying for example 
 the large articular folds, the external aspect of the limbs, etc. It 
 has a marked tendency to lichenization and consequently to prurigo 
 vulgaris. 
 
 Hematogenous pruritus is accompanied by a change in the blood 
 (leukemias and anemias), easily recognized when kept in mind and 
 looked for. 
 
488 NEURODERMATOSES— PRURITUS AND PRURIGO 
 
 Senile pruritus, described'hyVWillan, formerly covered almost all 
 the forms of pruritus of aged individuals. At the present time 
 this name is restricted to a chronic, almost invariably generalized, 
 remittent pruritus, in which the skin is flabby, dry, rough or smooth, 
 more or less senile, but very resistant to scratching. As a matter 
 of fact, even in severe senile pruritus, neither excoriations, nor 
 urticaria, nor papules, nor lichenization are noted. This form is 
 very rebellious to treatment. 
 
 Localized pruritus is provoked by and depends upon either a 
 local or a general cause. A general prurigenetic cause often 
 localizes its effects in a region which has first been irritated in some 
 way or takes advantage of an ordinary local lesion, such as varicose 
 veins or metritis, to lodge in its vicinity. The interest in this 
 localized pruritus is derived from the existence of these predisposing 
 conditions which it reveals and which can often be remedied. Not 
 infrequently it becomes eczematized, thereby leading to confusion 
 with the pruriginous eczemas, or it may also develop into prurigo. 
 
 Anal pruritus, which is perhaps the most common variety, at any 
 rate one of the most obstinate and demoralizing forms, is often 
 connected with the presence of oxyuris, lumbricoides, hemorrhoids, 
 fissures, or with habitual constipation. 
 
 Perigenital pruritus, sometimes associated with the preceding, is 
 frequently related to diabetes, cystitis, diseases of the prostate, 
 gonorrhea, or strictures of the urethra. Vulvar pruritus is suggestive 
 of leukorrhea, diseases of the vagina, uterus and adnexa; it is not 
 uncommon at the menopause or after spaying. It may create the 
 suspicion of or excite masturbation. 
 
 Nasal and peribuccal pruritus is often caused by' coryza, rhino- 
 pharyngeal lesions, dental caries, neglected inflamed gums, or 
 badly fitting artificial dentures. Buccal pruritus may occupy the 
 lips, the cheeks, as well as the tongue; it is often associated with 
 the neuralgia known as glossodynia. 
 
 Pruritus of the hairy regions is usually symptomatic of parasites 
 or of kerosis, pityriasis, etc. 
 
 Palmar and plantar pruritus, described by Alibert and Hebra, is 
 always symmetrical. It is rare and is encountered in unbalanced 
 and toxic persons. It often assumes the form of burning sensations 
 with nocturnal paroxysms. There is no trace of scratching. It 
 must be distinguished from dysidrosis and from eczema. 
 
 PRURIGO. 
 
 I employ the term prurigo to indicate that group of pruritic 
 affections in which the itching, which is the primary phenomenon, 
 becomes associated under the influence of scratching with special 
 
PRURIGO 489 
 
 cutaneous reactions, in the form of lichenization and prurigo 
 papules. 
 
 This definition, which is not given by all authors, is justified by 
 the historical development of this question and meets with the 
 nosographical requirements. 
 
 Willan grouped prurigo under his heading of papules, which 
 comprised: (1) strophulus; (2) lichen; (3) prurigo. Credit is due 
 to Cazenave and Canuet for recognizing that in prurigo the itching 
 is primary and the papule secondary. The elder Hebra again 
 reverted to the idea that prurigo is characterized by a primary 
 papule, a view which has since been refuted. Modern investiga- 
 tions, especially those of Brocq and Jacquet, have established the 
 almost universally accepted fact that the papules of prurigo and 
 lichenization are secondary to the pruritus and due to the 
 scratching. 
 
 Accepting the above definition (prurigo = primary pruritus + 
 special papules or lichenization), the diagnosis of the prurigos 
 becomes easy and the relations which they bear to associated 
 dermatoses are readily understood. 
 
 In 'pruritus, there may be traumatic lesions from scratching, 
 pyodermatitides and artificial eczema, but there are neither lichen- 
 ization nor prurigo papules. 
 
 Urticaria is a syndrome in which pruritus and scratching are 
 accompanied by the rapid appearance of very ephemeral urticarial 
 papules. In some forms of prurigo the skin is seen to react in 
 the form of urticaria, especially at the onset; the etiology of the 
 chronic urticarias coincides in its general outlines with that of 
 pruritus and the prurigos; we must therefore admit the existence of 
 a certain kinship between these two groups of dermatoses. 
 
 Eczema, irrespective of its cause, may assume a lichenoid appear- 
 ance and become extremely pruriginous. On the other hand, the 
 prurigos frequently become eczematized. It is readily understood 
 that the differential diagnosis between these two groups of cases, 
 lichenoid eczema and eczematized prurigo, resting as it does merely 
 on the priority of the pruritus or the eruption and on the more or 
 less diffused lichenoid state, often presents almost insurmountable 
 difficulties. 
 
 Several other pruritic dermatoses may ultimately become 
 associated with lichenization. The existence of secondary prurigos 
 may accordingly be admitted, as well as the more frequent occur- 
 rence of secondary pruritus. 
 
 Symptoms. — It is not necessary to repeat what has been said 
 about primary pruritus, its etiology, its pathogenesis and its clinical 
 manifestations. 
 
 The papules of strophulus and of prurigo have been already 
 
I'.HI 
 
 VEURODERMA TOSES—PRURITt 's AXD PRtJRlCfd 
 
 described (p. 1 10). All that remains to be discussed in this con- 
 nection is lichenization. 
 
 Lichenization (Besnier), which Mas first fully described by Brocq 
 under the name of lichenification, is a chronic more or less persist- 
 ent change in the appearance and the structure of the integument 
 (Fig. 147). The lichenized skin is thickened as a whole; it may be 
 described as striated, wrinkled, leathery, without either of these 
 words conveying an exact idea of the condition. Its peculiar 
 appearance is really characterized as an exaggeration of the fine 
 
 Fig. 147. — Lichenization of the skin of the internal aspect of the thigh, in a case of 
 prurigo vulgaris, in a woman aged forty years. 
 
 striae which normally traverse it, which results in a criss-cross net- 
 work with fairly regular meshes, more or less wide or narrow accord- 
 ing to the region affected, resembling the cross-hatching of an 
 engraving. The meshes are square, lozenge-shaped, or polygonal; 
 they have a flat surface and usually present the appearance of 
 smooth shining facets, like mosaic work. Sometimes they are 
 covered with fine scales. 
 
 The lichenized skin is less supple than the normal skin; its color 
 is normal, or more often of a grayish or brownish hue; sometimes 
 it is hypochromic. 
 
PRURIGO 491 
 
 Its histological structure is less altered than one might be led 
 to believe; the lesions consist of acanthosis, with elongation of the 
 papillae and moderate infiltration of the papillary body. 
 
 The lichenization occupies surfaces of very variable extent, in 
 patches or areas, with diffuse borders, where there is a gradual 
 transition to a normal appearance. [It is characteristic of the 
 border that it is not limited by curved lines but is made up rather 
 of short rectilinear elements.] On these borders, or on a surface in 
 course of lichenization, only a few shining polygonal facets are 
 noted, appearing very slightly papular; but not indurated. 
 
 Lichenization must be distinguished from: the patches of 
 lichen planus (Fig. 33) which are made up by the confluence of 
 genuine planus papules and surrounded by typical papules; and 
 from the lichenoid condition sometimes assumed by eczemas, 
 eczematides and psoriasis; this is characterized by thickening and 
 accentuation of the folds and furrows, but it is red, without shining 
 facets and distinctly circumscribed at its borders. The striated 
 and roughened condition sometimes presented by the skin of the 
 genitocrural regions in gonorrheic women, a condition described 
 by Brocq and L. Bernard, very closely resembles lichenization, 
 although the surface according to these writers, is more villous and 
 velvety. 
 
 Lichenization may be primary and pure, that is, it develops on 
 a previously healthy skin under the influence of rubbing and scratch- 
 ing caused by pruritus; under this form it is the principal and 
 most characteristic lesion of diffuse prurigo vulgaris; or it may be 
 associated with the above-mentioned dermatoses, lichen, eczema, 
 eczematides, etc. 
 
 Since lichenization is a peculiar reaction of the skin under the 
 influence of repeated traumatisms, the question may arise why does 
 it not develop on all surfaces exposed to friction, or in all pruritic 
 persons who scratch themselves. I shall restrict myself to giving 
 the explanations offered by Brocq, who says that some cutaneous 
 affections modify the vitality or the nutrition of the tissues in such 
 a way that lichenification occurs with the greatest facility, whereas 
 in other pruritic affections the resistance of the tissues seems to 
 be normal or even increased; moreover, some individuals are 
 especially predisposed to react in one or another way. [It must be 
 admitted that this explanation explains nothing; it simply restates 
 the facts.] The same theories are applicable to the pathogenesis 
 of prurigo papules. 
 
 As to the papules of strophulus, the question of their being of 
 primary origin or secondary to the scratching, remains doubtful; 
 it seems to me that they are often encountered at points of the skin 
 which the patient can in no way injure or scratch. 
 
402 NEURODERMATOSES— PRURITUS AND PRURIGO 
 
 Clinical Forms. — The prurigos constitute a continuous scries of 
 morbid types, extending from eases related to urticaria to formi- 
 dable dermatoses such as prurigo ferox. It would be desirable to 
 classify them into varieties and this has been attempted by many 
 dermatologists, who always emphasized those types which they 
 had been best enabled to study. Hence the subdivisions of some 
 do not agree with those of others and it is very difficult to find one's 
 way. Without aiming at completeness, I shall limit myself to 
 describing three principal forms: 
 
 Acute Prurigo Simplex or Strophulus. — The affection named 
 strophulus by Willan and Bateman and acute lichen simplex by 
 Vidal, was given by Brocq the excellent name of prurigo simplex 
 acutus, a name which has been received with general favor; abroad 
 the terms of urticaria papulosa and lichen urticatus are often 
 employed. 
 
 The condition is an acute benign prurigo, characterized by a 
 special and exclusive lesion, the strophulus papule, generally origi- 
 nating upon an urticarial base; an eruption advancing in rapid, 
 successive or overlapping crops, scattered over the entire body; the 
 usual absence of lichenization and eczematization; a limited dura- 
 tion, of a few weeks to a few months, but with possible relapses; 
 and on the whole a favorable prognosis. 
 
 Etiology. — Strophulus is of extreme frequency in early childhood ; 
 later in life it is observed much more rarely, but is not unknown, 
 however, in the period from fifteen to twenty-five years. 
 
 A predisposition in certain families is obvious. It is encountered 
 in apparently perfectly healthy children. However, two deter- 
 mining etiological factors can often be recognized: (1) Overfeed- 
 ing or underfeeding, digestive disturbances, gastro-intestinal fermen- 
 tations, constipation, etc.; (2) the influence of teething, which is 
 accompanied by nervous disturbances, excitement, insomnia and 
 often also by digestive disturbances. 1 have elsewhere pointed out 
 that the second period of life where strophulus is frequently met 
 with corresponds to that of the eruption of the wisdom teeth. 
 
 Symptoms. — Suddenly, in the midst of health, or sometimes 
 after a slightly febrile general malaise, lasting one or several days, 
 the eruption makes its appearance. It consists of urticarial 
 spots surrounding and at first concealing the papule which has 
 been previously described. Sometimes, a few urticarial elevations 
 without papules are likewise noted and are easily brought on by 
 scratching. 
 
 This eruption is located anywhere, at the onset preferably on the 
 upper extremities and on the trunk; later, on the lower limbs, on 
 the neck and on the face; the palms and the soles are only rarely 
 involved. 
 
PRURIGO 
 
 493 
 
 An eruption proceeds in crops of four or five, to about twenty 
 lesions; it recurs every day, or every second or third day. The 
 urticarial spot lasts only a few hours and then it fades, but the 
 papule lasts from four to ten days. It is therefore not uncommon 
 to see children covered with lesions of different ages (Fig. 148), 
 some incipient, others at their acme or undergoing retrogression; 
 and sometimes with not very persistent macules. 
 
 Sometimes the lesions are small vesicles originating on an urticar- 
 ial base; on the palms or the soles these vesicles may attain the size 
 of a lentil. 
 
 Fig. 148. — Profuse eruption of strophulus, or prurigo simplex acutus, in a boy 
 aged six years. 
 
 The course extends over a very variable period, from three 
 weeks to three months; recurrences are common in little children; 
 toward the age of three years the disease usually subsides. If it 
 persists, there is danger of the development of Hebra's prurigo. 
 
 Pruritus is variable and remittent, but often very severe. Some 
 individuals scratch furiously and excoriate some of their papules; 
 it seems, although this cannot be positively stated, as if the scratch- 
 ing gave rise to new papules. Eczematization and pyodermatitis 
 are rare. 
 
 The diagnosis rests upon the demonstration of the typical papule, 
 capped by a tiny lenticular yellow crust. In infants strophulus is 
 often confused with urticaria, the stings of insects, sudoral and 
 medicinal eruptions; in the young, with acne, papular erythema, 
 
494 NEURODERMATOSES— PRURITUS AXD PRURIGO 
 
 acute disseminated eczema. Cases where the eruption is plainly 
 vesicular may suggest varicella; it should be kept in mind that 
 the lesions of the latter are less pruriginous [are most abundant on 
 the back and frequent on the scalp] and do not spare the buccal 
 mucosa. 
 
 Prurigo simplex is evidently insufficiently known, for it is con- 
 stantly being re-described by physicians under some arbitrary 
 denomination. 
 
 The treatment consists in correcting and regulating the diet; it is 
 often advisable to diminish the quantity of milk and give a purga- 
 tive or laxatives, among which calomel is most to be recommended 
 for children. 
 
 Locally, acidulated, carbolized or anodyne washes are preferable 
 to baths, which are often not well borne. Zinc pastes with tumenol 
 and tar and occlusion by well-applied bandages when possible, are 
 effective against the itching. 
 
 Hebra's Prurigo. — From the chaos of the pruriginous diseases, 
 Ilebra picked out a morbid type which is designated under his name; 
 a mild form {prurigo mitis) is known, as well as a grave and chronic 
 form, characterized by a special course and by very polymorphous 
 and severe lesions. It corresponds to the lichen agrius of the 
 ancients and more or less accurately to the lichen polymorphe 
 ferox of Yidal. 
 
 As a rule the disease begins in the course of the first year of 
 life, in the form of urticaria or strophulus, with severe, recurrent, 
 very pruriginous attacks, but in many cases the pruritus comes on 
 directly, without premonitory eruptions. 
 
 At the end of a year or two, it reaches its fully developed stage 
 and the clinical picture is characteristic: The child is tormented 
 by incessant itching, or the pruritus may vary according to the 
 season of the year. The skin is covered with linear or papulo- 
 follicular excoriations, crusts, cicatrices, diffuse or regional eczema- 
 tizations, pyodermatitides; it is thickened, coarse, pigmented and 
 lichenized over large surfaces. The external aspects of the extremi- 
 ties are chiefly affected, less often the trunk and sometimes the 
 face; the large articular folds almost invariably escape. From 
 time to time, more or less large prurigo papules are encountered, 
 intermingled with the lichenization. 
 
 In the least scratched regions, the skin has an earthy color and 
 often resembles goose-flesh; the prominence of the follicles is attrib- 
 uted to contraction of the erector muscles. The hairs, although 
 abundant at first, soon become worn off and disappear. 
 
 The lymphatic glands of the groins and axillae are always enlarged, 
 and their enlargement is often very evident. Kosinophiles are 
 usually present in large numbers in the blood and in the skin itself. 
 
PRURIGO 495 
 
 The little patients are sickly, irritable, timid, their persistent 
 sufferings and habitual insomnia accounting for their gloomy 
 disposition. When they grow up, their infirmity condemns them 
 to a solitary existence; they can share neither in amusements nor 
 in attendance at school. 
 
 The course of Hebra's prurigo is remittent; periods of relative 
 calm are followed by aggravated attacks lasting several months. 
 It is usually not until puberty or even about the age of twenty to 
 twenty-five years that the disease subsides and becomes attenuated ; 
 from this time on, without knowing the patient's history, one might 
 mistake it for a chronic eczema or a prurigo vulgaris. The patho- 
 logical manifestations vanish as a rule in mature life or old age, 
 if the patient live long enough. 
 
 In the etiology, the hereditary conditions mentioned above rank 
 first in order, perhaps also to some extent errors in feeding in early 
 childhood. Like other observers, I have several times noted the 
 coincidence of Hebra's prurigo with asthma. [The possibility of 
 sensitization to a particular article or kind of alimentary substance 
 (e. g., milk, eggs) must be considered in the etiology.] 
 
 Several varieties of this prurigo may be described : 
 
 In the Hebra- Kaposi type, the cutaneous lesions increase in 
 severity from the head to the legs. 
 
 In what has been called the French type, they predominate on 
 the face and the upper extremities, being on the contrary less well 
 marked on the legs and on the trunk. 
 
 Prurigo ferox (polymorphous lichen ferox of Yidal) is a rare 
 type, characterized by prurigo papules scattered or grouped on the 
 extremities (Fig. 149), the body and even the face; they are of 
 considerable size, approaching the size of a cherry-pit or half a 
 hazel-nut, often excoriated or vesicular at their apex. On the other 
 hand, lichenization, while constant, is less pronounced. The itching 
 is intense and the disease is extremely obstinate and of indefinite 
 duration. 
 
 [Prurigo nodularis (Hyde) is closely related to the above. All 
 the cases described in America have developed in middle-aged 
 women. The lesion, five to twenty-five in number, located almost 
 exclusively on the extremities, are pea to hazel-nut in size, discrete, 
 often capped by small vesicles, intensely pruritic and rebellious to 
 treatment. The surrounding skin is normal in appearance.] 
 
 Cases of Hebra's prurigo of late onset may possibly occur; some 
 are of doubtful nature and liable to confusion with severe cases of 
 prurigo vulgaris; others are not infrequently referable to the leu- 
 kemias, especially to pseudo-leukemia with polynucleosis (prurigo 
 lymphadenique of Dubreuilh). 
 
196 
 
 NEURODERMATOSES PRURITUS AND PRURIGO 
 
 Prurigo Vulgaris, ruder this name 1 designate the common 
 form of prurigo, namely the group of cases which belong neither to 
 simple pruritus nor to acute prurigo simplex nor to I [ebra's prurigo. 
 
 A distinction is made l>et\\ een : I A diffuse or generalized form; 
 it corresponds in a considerable number of cases to the diathetic 
 prurigos of Besnier, to the diffuse neurodermatitis of Brocq, which 
 he lias more recently designated a- "diffuse pruritus with licheni- 
 fication." 2 A circumscribed form, corresponding to the circum- 
 scribed lichen- of the older author-, to the chronic lichen -implex of 
 Vidal, to the papular eczemas of Hebra and his school, to the 
 dermatitis lichenoides pruriens of Xeisser, to the circumscribed 
 neurodermatitis or circumscribed pruritus with lichenification of 
 Brocq. 
 
 I [g. 149 Prurigo ferox with large papules polymorphous lichen ferox of Vidal.) 
 
 Prurigo vulgaris is characterized by primary pruritus; poly- 
 morphous cutaneous lesions among which lichenization and eczema- 
 tization predominate; and by a generally subacute remittent course. 
 
 1. Prurigo Vulgaris Diffusa. Its etiology is that of the primary 
 prurigos in general, hereditary factor-, neurasthenia, metabolic and 
 nervous disturbances, abuse of coffee or alcohol, emotional causes, 
 all of these play an obvious role, as well as the diathetic nutritional 
 disturbances which are classified as "arthritism." 
 
 It may begin in childhood, but especially between twenty and 
 thirty years; it is less common after fifty. 
 
 The affection appear- abruptly, often after an emotional shock, 
 persisting for a few week-; then follow periods of subsidence and 
 intermittent recurrences, sometimes of seasonal type. 
 
PRURIGO 497 
 
 During the attacks the itching is continuous, with evening and 
 irregularly periodical crises; the scratching may at first give rise 
 to urticaria or erythema; but more or less rapidly, in different 
 individuals, sometimes in a few days, it leads to the production of 
 indistinctly outlined surface lichenizations, symmetrically occupy- 
 ing the four extremities, the thorax and the flanks and sometimes 
 the face, which becomes dull and grayish, with worn-off eyebrows. 
 The combination of this diffuse lichenization with medium-sized 
 and indistinct papules, with pigmentation, with traumatic eczema, 
 excoriations and pyodermatitis, constitutes a picture characteristic 
 because of its diversity (Fig. 150). 
 
 The disease is of indefinite durations covering months or years; 
 it may heal and is often replaced by asthma, hay fever, bronchitis, 
 enteritis, etc. 
 
 Fig. 150.— Diffuse prurigo vulgaris; right forearm of a young woman, aged twenty- 
 three years, whose four extremities presented similar lesions; these lesions consist of 
 diffuse lichenization, with pigmentation and numerous excoriated papules (diffuse 
 neurodermatitis consisting of pure lichenization, Brocq). 
 
 There are numerous varieties: Cases occur in which the prurigo 
 follows upon a long period of simple pruritus; or an eczema may 
 occupy the foreground, more or less concealing the other signs, so 
 that many of these patients pass under the label of chronic eczema ; 
 or the small and flat papules may lead to a confusion of prurigo 
 with lichen planus; and finally, there are intermediate cases, with 
 but few foci between the diffuse and the circumscribed form. 
 
 Under the name of prurigo hiemalis, a variety of this prurigo 
 described by Duhring is designated, more common in North 
 America, especially in men, characterized by its evident relation 
 to the cold season. The pruritus appears every fall, is more severe 
 in cold weather and ceases in the spring. The first attacks fre- 
 quently date back to childhood. The crises are vesperal and 
 nocturnal, or may occur in the daytime under the action of heat, 
 32 
 
498 NEURODERMATOSES— PRURITUS AND PRURIGO 
 
 The most common site of the itching is on the legs, the thighs and 
 sometimes the upper limbs. The condition is a simple pruritus 
 in some persons, but in the majority of cases becomes a prurigo. 
 
 J. Hutchinson has described a summer prurigo in every way 
 comparable to the preceding. 
 
 2. Prurigo Circumscripta or Lichen Simplex Chronicus of Vidal. — 
 The etiology is the same as in the diffuse form; sometimes there 
 exists a localizing cause, traumatism, internal lesion of the vicinity, 
 etc. Circumscribed prurigo is more common in women. 
 
 Its seats of election are the posterior portion of the neck, the 
 upper part of the thighs, the neighborhood of the genital organs 
 and the intergluteal fold, the external surface of the legs, the pop- 
 liteal and axillary spaces, the elbows and the posterior aspect of 
 the forearms; but it may occupy any area, including the palmar 
 and plantar regions. The focus is single, or there may be two, 
 three or more foci. 
 
 At the onset, there is only intermittent itching, excited by 
 occasional determining causes; next, it assumes the character of 
 distinct, especially vesperal crises, lasting a few minutes, with 
 furious scratching, followed by a voluptuous sensation of relaxation. 
 
 More or less rapidly, the lesions of prurigo develop and in these 
 cases present a typical appearance, in the form of a patch of chronic 
 lichen simplex of French writers, the lichen of Vidal of foreign 
 authors. It is generally oval, averaging the size of the hand; three 
 zones can be distinguished in it: 
 
 The external zone, 2 or 3 cm. wide, but imperfectly outlined, is 
 brownish, quadrillated, barely thickened. In the middle zone 
 appear lenticular and hemispherical prurigo papules, with an 
 excoriated or shining surface grouped near the central zone. The 
 latter is an infiltrated, hyperchromic or depigmented patch, lichen- 
 ized to the highest degree, with a scaly or macerated epidermis 
 according to the region and more or less distinctly outlined 
 borders. 
 
 Frequently the patches are not complete; the zones which repre- 
 sent the successive stages of the change may be missing on one side, 
 or altogether; the central disk may be replaced by more or less 
 closely agminated papules. 
 
 The duration of a circumscribed prurigo is from several months 
 to one or two years, sometimes still longer. Recurrences are 
 common. Sometimes, one or several new patches appear when the 
 old ones have ceased to itch, become flattened and smoothed out; 
 Inn the normal color is not restored until long afterward. 
 
 The differentia] diagnosis must be made from lichen planus, 
 lichen obtusus, the eczematides, the tubercular syphilides; it is 
 usually easy, especially with the help of the anamnesis. In addi- 
 
PRURIGO 499 
 
 tion to the rather common nerve or less marked pigmentary dis- 
 turbances, or leukomelanoderma, cases of circumscribed prurigo 
 occur in association with true vitiligo. 
 
 Treatment of Pruritus and Prurigo. — Needless to say, before 
 beginning the treatment of a pruritus or prurigo, the diagnosis of 
 its form and probable cause must have been specified as closely as 
 possible. 
 
 In the first place artificial pruritus, of parasitic origin or due to 
 external causes, must be eliminated; these require a parasiticide 
 medication or special hygienic precautions; next, secondary pruritus, 
 in which not only the symptom but the primary disease and its 
 complications require treatment. 
 
 In dealing with a primary pruritus or prurigo, its cause must be 
 looked for among intoxications, hygienic errors, organic or func- 
 tional anomalies; the urine and blood must be examined, etc.; it 
 goes without saying that the treatment must take into considera- 
 tion all the predisposing or determining factors which may have 
 played a part. 
 
 In a general way, the alimentary regimen must be as simple as 
 possible, in the form of a milk- or lacto-vegetarian diet, at any 
 rate free from all foods or drinks of a stimulating character or of 
 difficult digestion; it is especially important to insist upon careful 
 chewing, cleansing the teeth and keeping them in good condition, 
 counteracting constipation, etc. [The possibility that the under- 
 lying cause may be a sensitization to some article of food, often 
 common like eggs or milk, must not be forgotten.] 
 
 The inherent nervous element of every case of pruritus must be 
 treated by general as well as local measures and psychotherapy 
 may have to be utilized. 
 
 Rest and a quiet mode of life are indispensable in overwrought 
 or excited patients; the majority of sufferers from pruritus are 
 benefited by a sojourn in the country, in the mountains or by the 
 seaside. It has been observed that in the poorer classes, internment 
 in a hospital usually brings about rapid improvement, whereas 
 their discharge is followed by a prompt recurrence. Spinal punc- 
 ture, as tried by Thibierge and Ravaut, is sometimes followed by 
 a sudden and permanent improvement in these cases. The modern 
 practice is to recommend various sero-therapeutic procedures, injec- 
 tions of normal human serum, saline infusions, auto-hemotherapy, 
 hypertonic sera with glucose or magnesium salts, etc., although the 
 indications are not yet clearly established. 
 
 Sedative medicinal agents, bromides, valerian, antipyrin and 
 its analogues, carbolic acid, salicylates, etc., are of little value. 
 Extract of guaco is very unreliable. As a rule, tonics are called 
 for; cod-liver oil and arsenic, persistently administered, are often 
 
500 NEURODERMATOSES— PRURITUS AND PRURIGO 
 
 very useful in Hebra's prurigo, in the neurodermatitides and the 
 prurigo vulgaris of youthful debilitated patients. 
 
 Among physical agents, baths are often not well tolerated, even 
 with the addition of bran, starch, gelatin, lime blossoms, vinegar, 
 etc. It is infinitely preferable to utilize general showers either 
 lukewarm or barely warmer than the skin, applied with a very 
 gentle spray almost without percussion ("dew-like douches"), for 
 two, three or even four minutes or longer, repeated once daily or 
 even twice daily at the start. 
 
 Electricity, in the form of static baths, may soothe some cases of 
 pruritus; high-frequency currents are even more useful. 
 
 Watering-places suitable for patients with pruritus are, accord- 
 ing to the desired end: Bourboule, Xeris, Laxeuil, Bagneres-de 
 Bigorre, Saint Gervais, Loueche, Ragatz, etc.; sometimes, diuretic 
 or strong sulphur springs are indicated. 
 
 Local treatment is also of great importance. Aery hot rather 
 than lukewarm washes should be recommended, with one of the 
 antipruritic lotions indicated further on (Therapeutic Notes, sec- 
 tion 4). Then it is essential' to protect the pruriginous surfaces 
 from light and external irritants; this is accomplished by means of 
 occlusive dressings or more conveniently through application of 
 plasters, zinc gelatin or pastes, salves or varnishes, according to the 
 extent of the pruriginous surfaces and the regions occupied by it. 
 
 In the plasters and pastes, various tars may be advantageously 
 incorporated, especially tumenol or vegetable tar, or antipruritic 
 remedies such as menthol, phenol, camphor, various acids, etc. 
 I Inguentum glycerinii with tartaric acid and pure cod-liver oil in 
 inunctions or in salves or plasters, also possess a certain value. 
 
 In circumscribed pruritus or prurigo two or three radiothera- 
 peutic sessions (at a dose of 3 to 4 H every fortnight) are often 
 strikingly successful, but their effect is not always very lasting; in 
 case of repeated relapses, the applications must by no means be 
 inconsiderately repeated, for fear of radiodermatitis. High-fre- 
 quency currents act in a less brilliant fashion, but do not involve 
 the same disadvantages; scarifications, filiform douches and douches 
 of superheated air may be valuable adjuvants. 
 
 The essential point is not to regard any of these therapeutic 
 procedures as a panacea and as sufficient by itself, but to employ 
 them separately or together, according to the case, devoting special 
 care to the discovery and treatment of the individual conditions 
 [the causative factor] in a given case. 
 
 [I would particularly recommend the following plan of treat- 
 ment for the old patches of lichen simplex chronicus: The patches 
 are vigorously rubbed with a 10 per cent, solution of caustic potash 
 till the surface begins to be denuded of epithelium and shows many 
 
PRURIGO 501 
 
 oozing points. The burning sensation thereby produced is rather 
 agreeable to the patient. The surface, washed with water and 
 rapidly dried, is then painted with a solution of equal parts of 
 ichthyol (or thigenol) and water and dusted thickly with an indif- 
 ferent powder. The following day, treatment with the strong 
 salicylic-acid-chrysarobin-tar ointment proposed by Dreuw is 
 begun; an application is made night and morning for five days; 
 then follows a period of four or five days during which the patient 
 washes the affected area daily with soap and applies Lassar's paste. 
 At the end of this period the discoloration produced by the Dreuw's 
 ointment will have worn off and the patient is ready to begin the 
 course again, starting once more with the caustic potash applica- 
 tion, which should always be made by the physician himself. 
 
 For the temporary relief of itching in all forms of prurigo, raying 
 with ultraviolet light is of decided value.] 
 
CH AFTER XXV. 
 PARASITIC DERMATOSES. 
 
 Numerous parasites, animal or vegetable, may dwell on or in 
 the human skin, giving rise to very polymorphous affections. 
 
 The animal parasites, which are sometimes divided into epizoa 
 and dermatozoa, comprise insects, acari and worms. 
 
 The vegetable parasites or dermatophytes, with the exception of the 
 schizomycetes or bacteria, belong for the most part to the class of 
 niucedinia or filamentary fungi. Only the mucedini;e which vege- 
 tate in the epidermis and its adnexa, the hairs and the nails, will 
 be discussed in this chapter; the affections which they cause may 
 be designated as epidermo-mycoses. As to the true dermato-mycoses, 
 diseases due to dermatophytes growing in the corium, a special 
 chapter will be devoted to their discussion (Chapter XXVIII). 
 
 DERMATOSES CAUSED BY INSECTS. 
 
 The parasitic insects of man live for the most part on the surface 
 of the skin; they are epizoa. 
 
 Pediculosis and Phthiriasis. — Under these names are designated 
 the cutaneous lesions produced by lice. 
 
 Lice are insects of the genus aptera and the family of pediculi. 
 They have a pyriform head, provided with a sucking rostrum and 
 mandibles which can seize the skin; a thorax bearing six feet ter- 
 minating in a movable hook; and an abdomen not clearly sepa- 
 rated from the thorax. The females, more numerous and somewhat 
 larger than the males, lay a large number of eggs, with a chitinous 
 envelope, which are designated as nits. When they hatch, the 
 young resemble their parents and undergo no metamorphosis. 
 
 Three kinds of lice are parasitic on man: 
 
 Head-lice. — The head-louse, pedicuhts capitis, is about 2 mm. 
 long, of a rather slender shape, a gray color marked with black 
 spots on the border of the abdominal segments. It inhabits the 
 scalp, especially in children of both sexes and in careless women 
 and rarely the beard in men. In schools and asylums for pauper 
 children, lice are endemic; in the seventeenth and eighteenth 
 centuries, they flourished even at court in the heaped-up coiffures 
 of the great ladies. 
 
DERMATOSES CAUSED BY INSECTS 503 
 
 By their bites, lice cause severe itching, scratching and excoria- 
 tions; but these symptoms may be altogether absent in some 
 individuals. Without proper care, these lesions become infected 
 and instead of simple crusted papules, impetigo, yellowish crusts 
 adherent to the hair, folliculitis and abscesses of the scalp, pyo- 
 dermatitis and adenitis at the nape of the neck and the lateral 
 cervical regions, eczematization of the nape of the neck, the ears, 
 the face, etc., may be seen. 
 
 In a social environment of absolute neglect, the head of some 
 individuals may be found to be covered as with a cap formed by 
 matted hairs studded with innumerable nits, teeming with lice, 
 matted together by infected crusts with a nauseating odor; the 
 underlying scalp is bathed in pus. These extreme cases are desig- 
 nated under the names of trichoma or plica. 
 
 The deep follicular inflammations and abscesses may leave a 
 patchy cicatricial alopecia, which is incurable. The glandular 
 suppurations of the neck have been known to 
 lead to anemia, cachexia and generalized infec- 
 tions. 
 
 The lesions of pediculosis of the scalp begin 
 and predominate in the occipital region; a 
 pruritus or impetigo localized at this point is 
 suggestive of lice and these should be looked 
 for, irrespective of the age or social standing 
 of the patient. If they are not readily dis- 
 covered on parting the hair, at least nits may 
 be found appearing as white or grayish oval Fig. 151. — Pedicuius 
 grains stuck fast to the hairs in more or less capitis— male. After 
 
 ° . , , , t Kuchenmeister. 
 
 considerable number. 
 
 Treatment. — In boys or men, the hairs should be clipped close 
 to the head; in young women, the hair can almost always be spared. 
 
 In those cases where the hair teems with lice, it is customary in 
 the Saint Louis Hospital to begin the treatment with the application 
 on the head during one night of a thick layer of vaselin covered with 
 a bandage; the vaselin smothers and destroys the parasites. 
 
 When the lice are not so abundant, dressings with camphorated 
 alcohol left in place for a few hours, or washing with bichloride in 
 vinegar (1 : 500), or applications of powdered stavesacre or pyre- 
 thrum sometimes suffice to kill the lice and nits. To get rid of the 
 latter, it is advantageous after untangling the hairs to employ 
 a fine-toothed comb dipped in hot vinegar; the latter has the 
 property of dissolving the cement which fastens the chitinous 
 envelope of the nits to the hairs and of facilitating their removal. 
 When there are many crusts, these should be softened with sprays 
 or moist dressings, before removing them with soap and water; 
 
504 
 
 PARASITIC DERMATOSES 
 
 followed by the application of a sulphur, naphthol or salicylic acid 
 ointment or balsam of Peru. 
 
 Body-lice. — The body-louse or clothes-louse, pediculus corporis, 
 sen rrsiiiut uli, is longer, measuring nearly 3 mm., of a yellowish 
 white color and its abdomen has no black spots. It inhabits 
 especially the clothing in contact with the skin, flannels, shirts and 
 drawers; it is encountered among the poor, in tramps and in out- 
 ca>t> neglectful of all personal cleanliness. Unlike the head louse, 
 it attacks adults and old people rather than children. Lice have 
 abounded in the trenches during the war. The parasites or nits 
 are found especially in the folds, along the seams, where they are 
 accumulated in severe cases of pediculosis as a dense mass of yel- 
 lowish beady granules, stuck to the threads of the garment. They 
 are also found, however, on the body hairs, 
 notably at the pubis, in 90 per cent, of the 
 cases (H. Bulliard, 1917). The clothes-louse 
 is proverbially prolific; according to Leuwen- 
 hoeck, two breeding females may in the 
 course of two months produce 18,000 young 
 lice. 
 
 The bite of the body-louse gives rise to a 
 highly pruritic urticarial papule. The itch- 
 ing and scratching are especially severe in 
 the evening and at night. A sort of habit- 
 uation apparently becomes established in 
 inveterately lousy subjects, there is no 
 longer an eruption and the itching is not 
 conscious, although the scratching persists 
 instinctively, as shown by the linear excori- 
 ations following the scratch of the nails. 
 The shoulders and the upper portion of the back represent the site 
 of election of this pediculosis, next the abdomen, the loins and the 
 anterior aspect of the thighs. The face, the scalp and the feet and 
 hands are exempt. The excoriations may become the starting-point 
 of pyodermatitides. 
 
 [Body-liee have been shown to be carriers of typhus and possibly 
 also of "trench-fever."] 
 
 A long-standing pediculosis leads to a rather peculiar modifi- 
 fication of the skin, characterized by thickening, a dry and scaly 
 epidermis and especially a dark pigmentation; from this background 
 stand out the white cicatrices, recent excoriations and the innu- 
 merable crusts. This melanoderma of pediculosis (p. 329) is most 
 marked on the shoulders and the back, but may become generalized. 
 The pigmentation may be observed even in the mouth, a proof that 
 scratching does not sufficiently explain its genesis. 
 
 Fig. 152. —Pediculus 
 corporis — female. After 
 Kuchenmeister. 
 
DERMATOSES CAUSED BY INSECTS 505 
 
 A differential diagnosis in these cases must be made from Addi- 
 son's disease, in which pigmentation of the mouth is usually present. 
 But the topographical distribution of the Addisonian melanoderma 
 is different and itching and evidences of scratching are absent. 
 
 Asthenia and cachexia possess less diagnostic value, being, like- 
 wise encountered in the chronic pediculosis of poverty-stricken 
 subjects, which here assumes the appearance of a general disease, 
 known as Vagabonds' disease. 
 
 The differential diagnosis from the diathetic forms of pruritus 
 must take into consideration the different localization of the itching, 
 but is based especially upon the presence or absence of the parasites 
 and their nits. 
 
 The treatment consists in disinfection of the clothing in a steam 
 sterilizer and in the necessary personal cleanliness. 
 
 When no steam sterilizer is available, 
 the garments may be pressed out with 
 a hot iron or exposed to fumigations 
 with cinnabar; these measures, com- 
 bined with the persistent employment 
 of insecticide powders, the wearing of 
 clean linen and repeated washing with 
 soap and water, followed by parasiti- 
 cide inunctions (see Therapeutic Notes, 
 section 10) may be sufficient. 
 
 Pediculus Pubis. — Phthirius ingui- 
 nalis, popularly known as the crab- 
 louse, is nearly as broad as it is long, 
 vaguely resembling a crab; it lives an FlG 153 ._p e dicuius pubis. 
 the hairy regions of the pubis and After Schmarda. 
 
 vicinity, where it clings to two neigh- 
 boring hairs by means of the curved hooks of its feet. In hairy 
 men, it may invade the thighs, the entire trunk and the beard; in 
 both sexes it infests the axillae; in children and young women it 
 may even lodge on the eyelids, causing a blepharitis phthiriasica. 
 
 Crab-lice are usually acquired through sexual intercourse, but also 
 through indirect contagion, in water-closets, or infested bedding in 
 hotels. It has often been noted that this parasite is less common 
 in the very lowest class where personal cleanliness is absent, than 
 in the middle and even in the wealthy class. 
 
 Pediculus pubis gives rise to a very variable amount of itching in 
 different individuals and to scratching with its usual sequela?. 
 This etiology must be kept in mind in considering an eczema or 
 pyodermatitis of the regions mentioned. Together with the crab- 
 lice, nits will be discovered sticking to the hairs near their base. 
 
 A peculiar consequence of the bite of phthirius is the appearance 
 
506 PARASITIC DERMATOSES 
 
 of blue spots or shaded spots [taches bleues, taches ombrees, macules 
 ceruleoe], seen especially on the abdomen, the flanks and the thighs. 
 Formerly regarded as symptomatic of undetermined or even of 
 typhoid fever, these spots have been traced to their true cause by 
 Falot, Mourson and the experiments of Duguet [though their 
 pathogenesis is still unknown]. 
 
 Treatment. — The classical treatment with inunctions of blue 
 ointment — which should be rejected on account of the mercurial 
 eruptions so frequently (and stomatitis occasionally] caused by this 
 salve — is preferably replaced by inunctions with yellow precipitate 
 ointment of 5 or 10 per cent., or a white precipitate or naphthol 
 salve or balsam of Peru. Washing with bichloride-alcohol (1 : 500) 
 is also effective. [A salve containing three parts of ammoniated 
 mercury ointment and one part of blue ointment is safe and effective.] 
 In phthiriasis of the eyelids, Jullien recommended the removal of 
 the parasites one by one by means of a forceps. 
 
 Other Sucking Insects. — Fleas. — These are of various kinds, 
 each attacking a different animal. The human flea, pulex irritans, 
 lays its eggs in the dust of floors, etc. Its bite produces a character- 
 istic lesion; a hemorrhagic point surrounded by a lenticular zone of 
 erythema; this disappears in a few hours, whereas the central ecchy- 
 mosis persists several days. In children and in persons with an 
 irritable sensitive skin, an urticarial wheal forms at the onset; 
 [and in some cases, the wheal on subsiding leaves behind a papule 
 which itches periodically for several days]. Some individuals are 
 not attacked by fleas. In cases of extreme abundance of fleas, in 
 rag-pickers for example, the entire skin may be dotted with minute 
 red spots resembling purpura. 
 
 Fleas may act as carriers of the germs of severe infectious diseases; 
 there is reason to believe that these insects convey Bubonic plague 
 from rats to man. 
 
 Pulex Penetrans or Jigger. — This variety, Rynchoprion penetrans 
 or Dermatophilus penetrans, occurs in tropical America and in 
 Africa; the female burrows into the cutis, especially on the toes and 
 soles of the feet, where it grows to the size of a pea, causing a 
 furunculoid abscess. The loss of one or several toes, gangrene and 
 tetanus, may be the consequence of this "dermatophilia." 
 
 Bed-bugs. — The bed-bug, cimex lectularius, lives and multiplies 
 in wooden bedsteads, in cracks of wainscoting and in upholstery. 
 At night these animals sally forth from their hiding place and bite 
 the sleeper, producing red urticarial elevations on the skin, some- 
 times with extensive edematous swelling and a painful burning 
 sensation. They are suspected of being possible carriers of Oriental 
 boil, Bubonic plague, the trypanosomiases and Koch's bacillus. 
 
DERMATOSES CAUSED BY AC Alii 507 
 
 Mosquitoes. — This name is applied to an entire series of species 
 of culex, simulia, stegomya, anopheles, etc., distributed in all countries, 
 especially hot countries. The female sting the parts accessible to 
 them, especially at night, producing a rather persistent urticarial 
 swelling, particularly after scratching. 
 
 Great interest is, attached to these insects since it is known that 
 their various kinds serve as intermediary hosts and transmitters 
 for the parasites of malaria (anopheles), of yellow fever (stegomya), 
 of filariasis and perhaps also of pellagra (simulides) and of leprosy. 
 [The simulium theory of pellagra is no longer entertained.] Through 
 the systematic destruction of mosquitoes immense tracts of land 
 have been redeemed. 
 
 The treatment of the bites of fleas, bed-bugs and mosquitoes 
 consists in applications of alcoholic solutions of menthol or carbo- 
 lized vinegar, dilute ammonia, collosol, naphthalan, etc., followed 
 by bland powders. General prophylaxis, namely the destruction 
 of the insects, often presents serious difficulties. Protection 
 against mosquito bites is secured through the employment of 
 mosquito-netting [or by rubbing the exposed parts of the skin 
 with oil of citronella]; in a closed room, pyrethrum may be 
 burned. 
 
 DERMATOSES CAUSED BY ACARI (MITES). 
 
 The parasitic acari of men are in part true dermatozoa, living in 
 the horny epidermis, such as acari or sarcoptes, or in the pilo- 
 sebaceous follicles, such as demodex; and in part epizoa, such as 
 ticks, etc. 
 
 Scabies. — Scabies is a contagious parasitic dermatosis, caused 
 by an acarus, the Sarcoptes scabiei (Latreille), variety hominis 
 (Megnin) . It is extremely pruritic and is characterized essentially 
 by a special dermatological lesion, the burrow; and by polymorphous 
 accessory eruptions, having a regional and symmetrical distribu- 
 tion. 
 
 The ancients, confusing scabies, psora or the itch, with the pruri- 
 gos, interpreted it as a diathetic disease, subject to metastases, 
 which was treated by venesection and blood purifiers. It was in 
 vain that the parasite was pointed out by Mouffet (1634), C. 
 Bonomo (1687), Wichmann (1786). The truth was not established 
 until Renucci (1834), a student from Corsica, demonstrated in public 
 in the clinics of Alibert, the sarcoptes which his countrywomen had 
 taught him to know and extract (Fig. 154). 
 
 Symptoms. — The itch is observed in all social strata and at any 
 age; it is more common, however, among prostitutes and paupers 
 living in crowded quarters. 
 
508 
 
 PA RA SI TI C I) E R MA TOSES 
 
 The symptoms do not appear until after a latent period, averaging 
 
 ten days. 
 
 The eruption is localized or predominates in certain areas of 
 predilection, which should he systematically explored in all patients 
 
 Fig. 154. — Sarcoptes scabiei, male and female. Reduced from Furstenberg, after 
 Murray. 
 
 Fig. 155.— Scabies. 
 
 complaining of nocturnal itching. These are: the hands (Fig. 155), 
 the interdigital spaces, the lateral aspects of the fingers, the wrists, 
 more particularly their ulnar side, the elbows, the anterior wall of 
 
DERMATOSES CAUSED BY ACARI 
 
 509 
 
 the axilla, the ankles and the heels; in men, the sheath of the penis 
 and the glans; in women, the breasts; in children, the buttocks. 
 But the lesions may also occupy any other region, excepting the 
 head which always escapes and the neck and back which are usually 
 free. This topography in itself is characteristic. 
 
 The itch, however, has a pathognomonic feature, the burrows. 
 These are narrow grayish tracts, as if traced with the point of a 
 needle, taking a curved or sinuous course which does not correspond 
 to the folds of the epidermis. They have a length of 2 to 3 mm. or 
 more; Dubreuilh observed a burrow 4 cm. long on the foot. These 
 burrows represent the passages dug by the parasite in the horny 
 ayer of the epidermis. They are often dotted with black points 
 which indicate the exit orifices of the newly hatched larvse. Their 
 
 Fig. 156.— Scabies burrow. The shred of horny epidermis containing this burrow 
 was ablated with a razor; it is shown from its lower or deep aspect. A, entrance 
 orifice; B, black matter, excreta; C, opening; D, ova; E, acarus. X 50. 
 
 general color, which is darker in laborers and uncleanly persons, is 
 partly referable to the excreta left by the sarcoptes and also to 
 deposits of dust and dirt. White burrows may be found in the 
 better classes. 
 
 One of the extremities of the burrow, its head, is marked by a 
 small nacreous elevation, the acarus eminence of Bazin; this is a 
 tiny deep vesicle which forms in the vicinity of the sarcoptes. The 
 animal may be extracted by tearing off the roof of the burrow with 
 a needle and catching it in the cul-de-sac; or the entire burrow may 
 be excised by means of fine curved scissors or a razor (Fig. 156). 
 The burrows are most easily discovered on the fingers, the wrists, 
 the elbows, the penis, the heels, in general where there is a thick 
 epidermis, 
 
510 
 
 I'. 1 /,'. 1 SI Til • DERMA TOSES 
 
 The other lesions of scabies are accessory or secondary erup- 
 tions, of variable characters and abundance. At the onset, these 
 consist of spots of erythema or urticaria; next, of punctate or 
 linear excoriations produced by scratching, crusted miliary papules, 
 vesicles of dysidrotiform eczema, or ordinary eczema scattered or in 
 patches (scabietic eczema); and finally, of various pyodermatitides 
 —impetigo, folliculitis and ecthyma (scabietic ecthyma), suppu- 
 rating or dried into crusts which are scattered by the scratching and 
 may even be transported to the face. These lesions may become 
 complicated by lymphangitis, adenitis and cellulitis. Eczema of the 
 nipples and areolae in women ( Fig. 1 57 1 is always due either to scabies 
 or to pregnancy. The polymorphism of the scabies eruptions is a 
 characteristic feature, but their topographical distribution is even 
 more so. 
 
 The itching of scabies is usually almost intolerable. Its principal 
 attribute is its nocturnal character; it is especially pronounced at 
 the moment of retiring, but lasts until morning, often causing com- 
 plete insomnia. This time is the period of activity for the acari. 
 The itching is more or less localized or general. In some individuals, 
 scratching is unconscious; they scratch and flay themselves without 
 being aware of it. Pruritus may be absent although this is very rare. 
 [A moderate degree of eosinophilia is commonly present in the 
 blood of scabietics.] 
 
 Etiology. — The fertilized female of Sarcoptes scabiei is alone re- 
 sponsible for digging the burrows and causing the symptoms of 
 scabies. It has the shape of a flattened oval and measures one-third 
 or one-fourth of a millimeter; it is therefore visible to the nuked eye 
 as an opaque whitish point. The anterior two pairs of its eight feet 
 are furnished with cupping pads, the posterior two pairs with long 
 bristles. The males, which do not inhabit the burrows, are much 
 rarer and more difficult to discover; they are only half the size of 
 
DERMATOSES CAUSED BY ACARI 511 
 
 the females and their fourth pair of feet also is furnished with cup- 
 ping pads. 
 
 The ova, which the female drops behind her in the burrow, meas- 
 ure 0.16 mm. x 0.10 mm. and are more developed in proportion to 
 their nearness to the entrance orifice. They hatch in four to eight 
 days and the young leave the burrows through the openings to 
 settle elsewhere. 
 
 The sole cause of scabies is the transmission of the parasite. There 
 exist neither individual immunity nor predisposition. In view of 
 the habits of the sarcoptes, the contagion occurs almost exclusively 
 at night. It is necessary for an impregnated female to pass from an 
 infected to a healthy subject. This transmission is practically 
 inevitable in persons who share the same bed, hence family epidemics 
 and the frequent venereal origin of scabies. Contagion is possible 
 through unchanged bed-sheets in hotels, through clothing, through 
 sheets in sleeping-cars; it may very exceptionally result from con- 
 tact in daytime; it is very doubtful if it can occur through tools, 
 books, etc. 
 
 [Scabies is one of the commoner skin diseases. In the statistics 
 of American Dermatological Association it averaged about 5 per 
 cent, of all cases during a period of thirty years. In the first 
 decade of this century, however, there was a great increase in the 
 incidence of the disease and in 1908 it constituted 10 per cent, of 
 all skin diseases seen — a veritable epidemic. In general, scabies is 
 somewhat more frequent in European countries than in America.] 
 
 Prognosis. — Scabies never heals spontaneously. In some nervous 
 individuals it may end in marasmus, on account of the pruritus 
 and insomnia. Albuminuria is said to be not very rare in patients 
 suffering from the itch; it is attributed either to the toxins of the 
 sarcoptes or to nephritis caused by the microbes of suppuration. 
 
 In certain villages of Norway, Brittany, Italy, scabies was 
 endemic for a time; it persisted throughout life, usually without 
 causing severe symptoms. 
 
 In the course of febrile diseases, the symptoms of scabies as a 
 rule entirely disappear, recurring as soon as convalescence sets in. 
 
 Diagnosis. — The topography and polymorphism of the eruptions, 
 the nocturnal pruritus and the contagiousness, make the diagnosis 
 probable; the demonstration of burrows or of acari or their ova 
 makes it positive. 
 
 The essential point is to keep scabies in mind, whatever the 
 environment of the patient; not allowing one's self to be deceived 
 by the eruptions of strophulus, prurigo, dysidrosis, pediculosis, 
 eczema or pyodermatitis. 
 
 A real difficulty results from the obsession known as acarophobia, 
 or fear of the itch; this is observed in persons who have heard of it 
 
512 PARASITIC DERMATOSES 
 
 and especially in those who have had the disease and been treated 
 for it. When pruritus and eczema persist, after treatment by the 
 method called "la frotte" to be described presently, baths and 
 soothing creams should be recommended instead of hastening to 
 resume the treatment, unless new burrows are discovered. 
 
 Treatment. — In order to cure the itch, it suffices to destroy the 
 parasite and its ova; no internal treatment of any kind is required. 
 
 The classical "frotte" of the Saint Louis Hospital constitutes the 
 most rapid treatment. 
 
 It begins with rubbing the whole body vigorously with soft soap 
 for twenty to thirty minutes and continuing the friction in a warm 
 bath for another hour, in order to open all the burrows; during this 
 time the patient's clothes are disinfected in a steam-sterilizer. 
 Xext, the body is thoroughly rubbed with the Helmerich-Hardy 
 ointment, which is left on until the next day, when a full bath is 
 administered. 
 
 Less irritative sulphur ointments may be utilized, according to 
 the formulas of Bourguignon or Fournier (for examples see Thera- 
 peutic Notes, §10). 
 
 The "frotte" treatment must not be applied to young children, 
 pregnant women, patients with a very delicate skin or those suffer- 
 ing from extensive pyodermatitis. In such cases other substances 
 may be utilized, such as balsam of Peru, styrax, naphthol, etc., 
 which have been tried and approved but which must be employed 
 in moderate strength for eight to ten days in succession, at night, 
 preferably, after washing with soap; disinfection of the clothing is 
 not indispensable. 
 
 ("are must be taken always to examine the bedfellow and children 
 of the patient, as well as to treat on the same day all who have been 
 discovered to be infected. 
 
 Animal Scabies. — Scabies Norwegica or crustosa, described by 
 Danielssen and Boeck in lepers, also occurring in Germany and 
 various other countries, gives rise to thick and prominent incrus- 
 tations which may occupy the entire body, including the back and 
 the face. In all probability this condition represents not simply an 
 inveterate common itch, but a special parasitical variety, as was 
 maintained by Megnin, the sarcoptes of wolves. 
 
 Other animal itches, caused by sarcoptes other than the human 
 variety, are very rarely transmitted to man. The absence of 
 burrows has almost always been expressly noted. The eruption is 
 miliary or polymorphous, diffuse and pruriginous. These abnormal 
 itches may be derived from cats, birds, dogs, sheep, goats, camels, 
 pigs, etc. They are usually very readily curable or even subside 
 spontaneously. 
 
 The most noteworthy and serious form is equine scabies, of which 
 
DERMATOSES CAUSED BY AC Alii 513 
 
 I observed an example almost identical with the case published by 
 Besnier and Megnin in 1892. The appearance was that of a pity- 
 riasis rubra, completely generalized; the sarcoptes were demon- 
 strable by thousands in the scales and crusts; there were no 
 burrows. 
 
 Other Parasitic Acari. — Demodex Folliculorum. — This is a worm- 
 like acarus, measuring from 0.3 mm. to 0.4 mm., whose cephalo- 
 thorax is provided with a mouth and four pairs of rudimentary feet ; 
 the abdomen resembles the finger of a glove and shows fine trans- 
 verse striations. 
 
 This parasite inhabits the sebaceous follicles, especially the 
 mouths of the large sebaceous glands of the face, with its head 
 directed inward; a large number, ten or twelve, may be found in 
 the same follicle. 
 
 It has the reputation of being non-pathogenic, causes no inflam- 
 mation and certainly plays no part in comedo and acne vulgaris. 
 It was held responsible, however, by Dubreuilh, in a case of localized 
 pigmentation; personally, I have seen it so abundantly present in 
 the horny prominences of a lichen spinulosus that I was tempted to 
 attribute an irritative influence to it in this case. 
 
 Certain observations of Borrel would seem to suggest that the 
 demodex, or analogous acari, might intervene in the etiology of 
 epitheliomas of the face, as irritants or as carriers of a hypothetical 
 contagium, as well as in the etiology of leprosy. A disease of dogs, 
 known as follicular mange, not transferable to man, is due to a 
 variety of demodex. 
 
 Leptus Autumnalis (rouget or aoutat) is the larva of a trombidium 
 holosericum which lives on vegetables, notably on beans, wild grapes 
 and many varieties of grasses. Certain regions have for a long time 
 been infested with it; at present it is spreading in numerous locali- 
 ties in the vicinity of Paris. These mites flourish in the summer- 
 time and attack those visiting fields or gardens; attaching them- 
 selves to the legs, the thighs, the waist and the axillae, especially 
 where a band such as a garter or belt, etc., retains them; but they 
 are found even on the ears and the face. They cause a frightfully 
 itching urticarial papule which the patients scratch off with their 
 nails. Careful inspection, preferably with a lens, reveals the para- 
 site in the form of a blood-red dot, measuring from \ to ^ mm. in 
 the follicular mouth of a hair; often several are seen together. 
 Under the microscope, they resemble cheese-mites, but of a red 
 color. 
 
 Infection may be guarded against by rubbing with tincture of 
 benzoin or oil of cade. The treatment of the very distressing 
 eruption caused by the parasite consists in washing with benzene 
 or applications of Peru balsam or tincture of iodin. 
 33 
 
514 PARASITIC DERMATOSES 
 
 Ixodes (Ticks).- — The most common (in Europe) is i.nxles ricinus, 
 the wood-tick, a large brownish acarus which in the fasting state 
 measures from 3 to 4 mm.; its body becomes globular and con- 
 siderably swollen when the animal is gorged with blood. It attacks 
 dogs, cattle and large game, but rarely human beings. 
 
 Argas. — Argas reflexus marginatus, closely related to the ixodes, 
 is of similar size and has the appearance of a small gray shield. It 
 is a pigeon-parasite and infests dove-cots. When it accidentally 
 bites man, a very painful extensive phlegmonous edema has been 
 known to follow, with vesiculation or generalized urticaria, dis- 
 tress, tachycardia and digestive disturbances; these symptoms are 
 undoubtedly due to inoculation with septic germs. Other species 
 of argas and ornithodorus may transmit to man various pathogenic 
 agents, notably the spirochete of "tick-fever," etc. 
 
 Pediculoides Ventricosus. — In laborers engaged in unloading 
 exotic cereals from various countries and on the boats which carry 
 these cargoes, one may observe, sometimes in epidemic form, an 
 extremely pruritic erythemato-papular eruption caused by the 
 acarus which bears this name. It measures from 120 to 200 fx. 
 in length by 70 to 80 /jl. in width. Washing with dilute vinegar 
 suffices to cure these patients. [The parasite is conveyed in wheat 
 straw and considerable endemics of an urticarial disease have 
 occurred in consecmence of the use of the infested straw for making 
 cheap mattresses.] 
 
 DERMATOSES CAUSED BY WORMS AND LARWE. 
 
 Among the numerous parasitic worms of man, only one really 
 lodges in the skin, namely filaria medinensis. 
 
 Filaria Medinensis or Dracunculus. — This is a nematode worm 
 occurring in many tropical countries, notably in Western Africa 
 ((juiiwa-worm). 
 
 The adult female is filiform and from GO to SO cm. long; it remains 
 rolled up in the frequently single abscesses which its presence 
 produces, usually on the feet or legs. The filaria is ingested by 
 drinking stagnant water in which the embryos have been deposited 
 and have penetrated into a small crustacean, a cyclops (Manson) 
 [which serves as an intermediate host]. It is not until a year later 
 that a fecundated female filaria emerges at the skin. 
 
 In place of the classical treatment, namely extraction of the 
 worm by pulling and rolling it up on a small stick, in which 
 rupture is a common and dangerous occurrence, it has been 
 recommended to inject a solution of bichloride, 1 to 1000, in the 
 vicinity of the worm, which dies and is then more easilv extracted. 
 
EPIDERMOMYCOSES 515 
 
 Filarial elephantiasis (Chapter XVIII) cannot be interpreted 
 simply as a parasitic dermatosis. 
 
 Various eruptions have been reported as due to other kinds of 
 filaria. Craw-craw is a pruritic papulo-vesicular, later ulcerative 
 dermatosis of the feet and legs, observed in Western and Central 
 Africa. It is imperfectly known and has been referred to micro- 
 filaria (O'Neil), larvse (Nielly), etc. 
 
 Pani-ghao, or ground-itch of Assam and the United States, is a 
 papulo-vesicular and pruritic dermatitis due to the larvse of ankyl- 
 ostoma duodenale [hook-worm] having penetrated into the skin of the 
 feet or legs. 
 
 Cysticercus Cellulosce. — This parasite is sometimes present in the 
 subcutaneous tissue of man as well as pigs and is apparently more 
 frequent in Germany than in France [and very rare in America]. 
 The cysticercus cellulosse is the vesicular form of tenia solium. The 
 parasites appear as small and hard, round nodules, the size of a 
 large cherry pit, present in more or less considerable number in the 
 hypoderm or more deeply, causing neither pain nor inflammatory 
 reaction. They contain a clear fluid and a scolex provided with its 
 hooks and suckers. The tapeworm whose ova have caused the 
 infection not infrequently inhabits the intestine of the patient him- 
 self or that of a person in his environment. 
 
 The treatment requires the extirpation, or better, electrolysis of 
 each nodule with the positive pole. 
 
 Larva Migrans. — Under this name is designated the parasite of 
 a very peculiar affection named creeping disease, pointed out by 
 H. G. Lee, in 1874 and 1884. It is characterized by a red line, 
 1 to 3 mm. wide, irregularly winding and undulating on the skin, 
 sometimes forming knots and loops; its extremity advances from 
 1 to 10 cm. daily. This dermatosis is not uncommon in Russia. 
 It is difficult to seize the parasite; it is a very motile, black-headed, 
 1 mm. long larva of a gastrophilus or horse-fly. The affection may 
 be cured by tincture of iodin or bichloride of mercury [by injections 
 in front and around the head of the advancing line.] 
 
 Various cutaneous myases due to the larvse of flies (oestridse and 
 muscida?) are related affections. 
 
 EPIDERMOMYCOSES. 
 
 The epidermomycoses are caused by mucedinese and are purely 
 local affections, without reaction upon the general health. 
 
 Among the thread fungi which are entitled to the name of epi- 
 dermophytes, some affect preferably the scalp (tinea XX) or the 
 beard (sycosis, XIX) and the nails^ (onychomycoses XXI). 
 
 The same species may also vegetate upon the hairless skin, while 
 
516 PARASITIC DERMATOSES 
 
 others affect it exclusively; in this way the erythematosquamous ( V) 
 and eczemaUform mycoses (IV) originate. 
 
 Favus. — Under this name is designated an epidermomycosis due 
 to the achorion Schonleinii. 
 
 Favus, formerly confused like the tineas with porrigo and impetigo, 
 was separated by Biett and the brothers Mahon. Its parasite was 
 discovered by Schonlein of Zurich, in L839, well described by 
 Gruby and christened by Remak. 
 
 Favus is essentially a rural disease, is not limited to children and 
 produces crusts and cicatrices; a spontaneous cure is exceptional. 
 These features differentiate it from the other epidermomycoses. 
 
 The characteristic eruptive lesion of favus is the scUtulum, a 
 saucer-shaped crust 2 to 4 mm. in diameter, thick in proportion, 
 of a sulphur yellow color, usually pierced by a thick or downy hair. 
 
 #1- 
 
 Fig. 158. — Favus; spores and separate mycelic fragments. X 900. 
 
 The cup or scutulum originates as a mass of white matter in a 
 follicular funnel and at first resembles a small pustule. This mass 
 grows and extends in the horny layer, part of which covers it for a 
 certain length of time; then it dries, becomes depressed, yellow and 
 friable. In three weeks the cup attains a diameter of '.\ mm., and 
 may grow still larger. More frequently, neighboring cups of differ- 
 ent si/es become agglomerated into an irregular roughened mass 
 which has been compared to a honeycomb (favus) and has a mousy 
 odor. 
 
 The material of a favus-cup is easily broken up into a grayish 
 dust. Examined under the microscope, in a drop of 40 per cent, 
 caustic potash or of formic acid, the cup appears composed of spores 
 in great numbers and short tubes of mycelium (Fig. 158). The 
 mycelial segments, from 4 to 15 fx. long, from ."> to 7 ix. wide, 
 are of irregular form, present short lateral branches and often ter- 
 minate in a row or tuft of cubical members or spores. These spores 
 are rounded, oval or irregular, and of varying diameter; they con- 
 sist like the tubules of a granular protoplasm and a not easily 
 differentiated membrane, 
 
SPIDER MOM YC 'OSES 
 
 117 
 
 The achorion is characterized by its abundance as well as by the 
 irregularity and clumsiness of its forms. 
 
 In a cross-section of a favus cup (Fig. 159) which is made up 
 entirely of parasites, one finds at the base, slender imperfectly 
 partitioned threads; in the middle layer, thick sporulated threads, 
 at the surface, short members and spores; the whole may be 
 covered with lamellae of horny epidermis. 
 
 Malassez observed in a case of favus that the mycelial tubes 
 penetrated under the cup as far as the connective tissue of the cutis, 
 without exciting a special inflammatory reaction. His specimens, 
 which I was enabled to study, are convincing and have been endorsed 
 by all histologists who have seen them; but such a penetration is 
 exceptional and has never again been demonstrated by myself or 
 by others. It certainly does not explain the inflammatory reaction 
 caused by favus and the cicatrices which it leaves behind. 
 
 Fig. 159. — Favus; cross-section through a cup imbedded in the epidermis. X 60. 
 
 I have personally described with J. Halle (1910), under the name 
 of granuloma favosum, intradermic tuberculoid nodules surrounded 
 by a ring of giant cells, found on the scalp in a case of favus. These 
 are very rare and are probably due, like the trichophytic granulomas 
 of Majocchi, to the destruction of hair follicles. 
 
 In a scale of epidermic favus without cups there are found not 
 only a very irregularly partitioned mycelium but also collections of 
 spores which are not seen in herpes circinatus trichophyticus. 
 
 The dull and discolored hairs, in favus, are not brittle like tricho- 
 phytic hairs, because the parasite is much less abundant in the 
 favus hairs. One finds in them a variable number of greatly twisted 
 tubules, either thick and sporulated, or slender and more rectilinear, 
 composed of segments from 12 to 15/x in length, dichotomized at 
 an acute angle and generally surrounded with air-bubbles, which 
 at once indicate their presence. 
 
518 PARASITIC DERMATOSES 
 
 In favus of the nails, the ungual cells are dissociated by irregular, 
 slender or very bulky filaments or by spores; this appearance is not 
 characteristic. 
 
 Cultures of a particle of a cup or of the root of a favus hair, on 
 peptonized agar, yield in three or four days, at a temperature of 90° F., 
 a star of white radiating filaments; by the end of three weeks this 
 has become an irregular patch, 2 to 4 cm. in diameter, with an 
 irregular undulating surface, of a yellowish gray color, smooth or 
 covered with a scanty whitish down; its periphery sends out branch- 
 ing and nodular radiations. 
 
 The achorion Schonleinii belongs botanically to the genus oospora; 
 it is responsible for practically all cases of human favus. Due to 
 the remarkable investigations of Sabrazes, Bodin and others, we 
 know at the present day several other species of achorion in animals 
 — mice, cats, dogs and poultry (achorion Quinckeanum, gallinum, 
 gypsceum, oospora canina); but these have been very rarely met 
 with in men, in trichophytoid eruptions, sometimes with minute 
 cups, but never on the hairy scalp. 
 
 Etiology. Favus is contagious, although to a less degree than 
 trichophytosis and is rarely epidemic. It is hardly ever contracted 
 otherwise than in the course of childhood, from five to fourteen 
 years, at school or at home; it frequently happens that of several 
 children who live together only one or two are attacked. As favus 
 has practically no tendency to a spontaneous cure, it may persist 
 throughout life and become perpetuated in certain families and 
 localities. 
 
 Transmission from one human being to another is the rule and 
 may be direct or through the medium of clothes, head-coverings or 
 toilet articles. Favus of animal origin, as stated above, is extremely 
 rare. 
 
 Favoring conditions are dirt, poverty and promiscuity. In Paris, 
 cases of favus are almost without exception imported from the 
 country or from abroad. The disease tends to diminish in France; 
 it is still most frequently met in Lyons, in the northwest and in the 
 south. Favus is rare in England and America, but common in 
 Poland, Italy, Holland and Algeria. 
 
 Clinical Forms. — Tinea favosa (XX) and onychomycosis favosa 
 (XXI) have already been described. I have also pointed out the 
 characteristics of the alopecia and cicatrices due to favus (XVII). 
 
 Favus of the glabrous skin is not very rare, but is found especially 
 in persons whose scalp has first been infected, so that it is generally 
 the result of auto-inoculations. The face, the shoulders, the ab- 
 domen, the buttocks and the external aspect of the limbs may be 
 attacked. No positive case of favus of the mucous membranes is 
 known; the observation of Kaposi and Kundrat, concerning a 
 
EPIDERMOMYCOSEX 
 
 519 
 
 favus patient who died with gastro-intestinal ulcerations, is open to 
 question. 
 
 There are two varieties of favus of the hairless regions (Fig. 160) ; 
 the circinate epidermic variety (favus herpeticus) closely resembles 
 circinate trichophytic herpes, although it assumes a less regularly 
 circular form; the epidermis of the red and scaly spots contains an 
 abundance of short mycelial threads, spores and irregular tubules; 
 the cupped variety develops as such from the start, or more often 
 originates from the preceding form with the appearance of follicular 
 yellow disks which grow at a rapid rate. 
 
 Fig. 160. — Favus of the hairless skin; the epigastrium of this young girl presents 
 two spots, one of which bears four cups, the other being of the variety known as favus 
 herpeticus. 
 
 Treatment. — Favus of the body is much more easily curable than 
 favus of the hairy regions. It suffices to soften the cups with moist 
 dressings, to remove them by scraping with the curette and to make 
 two or three applications of tincture of iodin. As a rule, there remain 
 no cicatrices, but only simple macules. Recurrences must be 
 guarded against by carefully watching the patient. [The treatment 
 of favus of the scalp has been discussed in chapter XX.] 
 
 Trichophytosis. — In a series of remarkable contributions, pub- 
 lished from 1841 to 1845, Gruby established the parasitic character 
 of the tineas. Credit is due to Bazin for the universal recognition 
 of this fact. During fifty years one of these parasites, named the 
 trichophyton tonsurans, by Malmsten, was assumed to be the sole 
 
20 
 
 PARASITIC DERMATOSES 
 
 cause of tinea tonsurans of children, sycosis parasitaria of men, 
 herpes circinatus trichophyticus and onychomycosis. 
 
 This view was altogether changed b\ the admirable investi- 
 gations of Sabouraud, who confirmed the descriptions of Gruby, 
 but applied bacteriological methods to the study of the tinea-. He 
 recognized the fad confirmed after him b\ Mibelli, Bodin, ( '. Fox, 
 yi ^Jorris, etc. thai the pathogenic trichophytons of men and of 
 animals do not belong to one and the same species, but constitute 
 a family of numerous genera, varying in their morphology, their 
 cultural features, their habitat and the clinical lesions they give 
 rise to. 
 
 fticus circi 
 
 iti). 
 
 Moreover, one of the parasites described b\ Gruby in porngo 
 decalvans is not botanically a trichophyton; it is called micro- 
 sporon and the tinea produced b\ it bears the name of tinea tonsurans 
 w ith small spores [microsporia] of Gruby-Sabouraud. It will be dis- 
 cussed further on. 
 
 Trichophytons. The true trichophytons belong to the genus 
 botrytis, family mucedinea?. 
 
 I,,' their epidermic products, the trichophytons assume the shape 
 of mvcelium threads and -pore-. The mycelium is made up of 
 elongated, slightlv undulating, regular, colorless and transparent, 
 
EPIDERMOM YCOSES 52 1 
 
 partitioned and branching tubules (Fig. 161); the partitions are 
 usually very close together. In each compartment a rounded, 
 oval or cubical spore is formed; these spores often remain in rows 
 or strands. 
 
 For the microscopic examination of scales, hairs or nail clippings, 
 it suffices to place these on a slide, add a drop of 40 per cent, potash 
 solution, cover with a slip and heat gently over a flame to a tem- 
 perature near the boiling-point. Formic acid also clears up the 
 scales after a little time without heat. Amplification from 200 to 300 
 diameters is the most convenient. In order to obtain stained and 
 lasting specimens, the epidermic particles must be rendered free 
 from fat with alcohol and ether, stained with Sahli's blue and 
 mounted in Canada balsam. 
 
 Trichophyton cultures are obtained without difficulty on agar 
 media containing 1 gram of peptone and 4 grams of glycerin or sugar 
 to 100 grams of water. Barely visible particles of hairs or scales 
 should be planted aseptically and the test-tubes left without rubber 
 caps at laboratory temperature. Very often the cultures are pure 
 from the start, without its being necessary to begin by first washing 
 the material in alcohol or silver nitrate, as recommended by some 
 authors. After the third day, secondary cultures can be made, 
 preferably on the test medium of Sabouraud, which gives the most 
 distinctive physiognomy to the various species and is composed as 
 follows: Granulated peptone (Chassaing), 10 parts; crude maltose 
 (Chanut), 40; agar-agar, 18; water, 1000 parts. A temperature 
 from 75° to 95° F. is the most favorable. 
 
 Besides the mycelium, the following organs of fructification of 
 the trichophytons are found in these cultures: Spore-bearing 
 hyphens usually in terminal clusters, exceptionally endoconidia and 
 also, according to the species, more or less numerous multilocular 
 spindles. 
 
 The number of known species of pathogenic trichophytons is 
 about thirty. 
 
 It has been shown by the investigations of Plato (1902), followed 
 by those of Truffi, that a triohophytine can be extracted from the 
 cultures of several trichophytons, which when injected into a patient 
 having trichophytosis with deep nodes will give rise to a cutaneous 
 and a general reaction not occurring in healthy persons. An extract 
 of achorion culture, or favine, seems to act even more constantly. 
 These injections or applications of salves containing the toxins, 
 might serve for the treatment of the deep trichophytoses. Bruno- 
 Bloch and Massini have confirmed these observations and have, 
 moreover, succeeded in immunizing animals against the tineas in 
 general, by a preliminary inoculation w T ith trichophyton gypseum 
 or an animal achorion. Investigations in this direction now under 
 
522 PARASITIC DERMATOSES 
 
 way promise important results from the standpoint of diagnosis, 
 prophylaxis and treatment. 
 
 Clinical Forms. — The trichophytons give rise to various cutaneous 
 affections, according to their localization on the scalp, the hairless 
 skin, the beard or the nails. 
 
 Tinea trichophytica has been described elsewhere | XX). It maybe 
 due to several species. According to Sabouraud, it may be stated that 
 at the present writing, of 101) cases of this affection in Paris, .10 are 
 due to the trichophyton crateriforme, 30 to the trichophyton acumina- 
 tum; and the 20 remaining eases are due to various species among 
 which the trichophyton violaceum predominates. In other countries, 
 these proportions would undoubtedly be different. 
 
 The granuloma trichophyticum of Majocchi (1883-1906) is a rare 
 form characterized by intradermic nodules, sometimes agminated 
 or in strands, which develop in the cutis of the alopecic and squam- 
 ous spots; they consist of a mass of inflammatory cells and a ring 
 of giant cells surrounding fragments of trichophytic hairs. Pini 
 and Lutati have observed a few similar cases. 
 
 Sycosis trichophytica of the beard, kerion Celsi and folliculitis 
 agminata which have already been described in this book (XIX), are 
 follicular, inflammatory and even suppurative forms of trichophy- 
 toses of animal origin. Their most common germ is the trochophyton 
 gypseum of horses; sometimes it is a bird trichophyton with rose- 
 colored cultures. These parasites are ectothrix; they possess pyo- 
 genic properties. Adults are more susceptible to the contagion 
 than children; it results either from direct contact with the tricho- 
 phytic animal — horse, dog, cow, birds, etc., whose lesions may not 
 always be very evident — or indirectly from the handling of con- 
 taminated articles, brushes, coverings, etc. Transmission may then 
 take place from man to man, by intermediation of the barber, for 
 instance. The sequence of cases is often difficult to establish. 
 
 Jadassohn has pointed out in children suffering from kerion, the 
 frequent co-existence of not very persistent folliculitides of the 
 trunk, supposed to be of toxemic character and designated as 
 disseminated lichenoid trichophytosis. The above statements on the 
 etiology of sycosis are likewise applicable to that of onychomycosis 
 trichophytica. 
 
 Cutaneous trichophytosis of the hairless- .shin was formerly known 
 under the name of herpes drcinatus which also comprised cutaneous 
 microsporia and epidermophytosis. 
 
 Cutaneous trichophytosis is observed in: 
 
 1. Children suffering from tinea and persons in their environment; 
 these cases are usually due to one of the ordinary endothrix tricho- 
 phytons of the tineas. It is not uncommon, as was first pointed out 
 by Besnier, that the epidermic manifestation which is very evident 
 leads to the discovery of a previously undetected tinea tonsurans. 
 
EPIDERMOM YCOSES 
 
 523" 
 
 2. Persons of all ages, free from tinea, whose occupation or incli- 
 nation puts them in frequent contact with animals. In these cases, 
 the parasite is presumably an ectothrix of animal origin and does 
 not invade the scalp. 
 
 Any region of the body may be involved; the seat of election of 
 cutaneous trichophytosis, however, is the exposed parts, such as the 
 face, neck, hands and forearms. Its palmar and plantar localization, 
 of special appearance, has been mentioned under the heading of the 
 keratodermas (p. 216). 
 
 Trichophytosis of the hairless parts manifests itself in the form of 
 erythemato-squamous spots, noteworthy on account of their strictly 
 geometrical orbicular circumference and their distinctly outlined 
 clean-cut borders (Fig. 162). This feature at once attracts atten- 
 tion. It is altogether exceptional for the disk to be incomplete or 
 
 Fig. 162. — Spot of herpes circinatus trichophyticus on a child's neck. 
 
 the circle broken. When the affection is lodged on the fingers, the 
 circle is continued from one finger to the other, just as at the eye or 
 mouth it passes from one eyelid or one lip to the other. 
 
 The spot is pink or red, often with a dusky center, covered with 
 powdery, flaky or crusted scales; it is marginate or plainly cir- 
 cinate through healing from the center. 
 
 Another valuable but inconstant characteristic is the vesiculation 
 noted at the border of the spot; vesicles may be observed over the 
 entire lesion, or there may be several concentric circles of vesicles 
 (up to 7 on a cast in the Saint Louis Hospital). Sometimes, the 
 vesicular contents are turbid or purulent. The vesiculation is of the 
 eczematous type. 
 
 The floor of the spots is sometimes more or less edematous or 
 infiltrated. The downy hairs may be dull and brittle or encased in 
 scales at their base. Itching is very variable in its severity. 
 
524 PARASITIC DERMATOSES 
 
 All these variations arc much more dependent upon the kind of 
 trichophyton involved than upon individual or accessory factors. 
 
 As a rule, all the spots arc of the same type in a given case 
 
 The coiir.se of herpes circinatus is almost always rapid; in a few 
 days, a spot will reach the dimensions of a silver quarter; the exten- 
 sion of the borders may he more than 1 nun. daily for some species. 
 Slightly older patches may reach the size of the palm or the entire 
 hand. Very frequently these spots are multiple and of different 
 ages, the most recent spots being the result of re-inoculations. It 
 was formerly taught that the confluence of two or more lesions may 
 give rise to polycyclic spots or arabesques and that a considerable 
 portion of the integument may become invaded; in all probability 
 many cases of this kind belong to the group of epidermophytosis. 
 
 The diagnosis of herpes circinatus is often obvious at once 
 through the clinical features; in doubtful eases, it will be con- 
 firmed by the microscopical examination of the scales from the 
 periphery of the lesion. The parasite here appears in the form of 
 band-like, slightly wavy, fairly regular, often bifurcated mycelium 
 filaments, composed of short members (Fig. 161); even unstained 
 specimens show the very close partitions between the square or 
 rectangular segments, which is not the case in the mycelium of 
 epidermic microsporia. 
 
 ( 'onfusion of herpes circinatus must be avoided with the trichoph- 
 ytoid patches of common eczema, which are less regularly out- 
 lined and accompanied by scattered eczematous lesions; with the 
 eczematides, whose configuration is less orbicular and whose course 
 is slower; with pityriasis rosea of Gibert, which Kaposi persistently 
 classified under "herpes tonsurans maeulosus,'' but which is dis- 
 tinguished by is course, its ovaloid patches and the absence of 
 vesiculation; it is only the primary patch which may sometimes 
 require microscopical examination. 
 
 The distinctive features differentiating the cutaneous trichophy- 
 toses from epidermophytosis will be discussed presently. Under 
 certain special circumstances, the question of a differential diagnosis 
 from various exotic epidermomycoses may arise. 
 
 Treatment by painting with pure tincture of iodin, repeated 
 three times at intervals of two days, or with 1 diluted iodin 
 tincture in daily applications; or with iodinized vaselin 1 to 
 Mid, leads to a cure of herpes circinatus in from ten to fifteen 
 days. This medication has replaced the formerly classical employ- 
 ment of turpeth-mineral sake I to 1.") and of naphthol ointments. 
 
 Epidermophytosis Inguinalis (Eczema Marginatum of Hebra). — 
 The cutaneous affection described by Pr. Hebra, under the name of 
 eczema marginatum was recognized as of mycotic origin by Ivobner, 
 Pick and Kaposi, but continued to be confused with the cutaneous 
 
E I' IDE HMO M YCOSES 525 
 
 trichophytoses. The accurate investigations of Sabouraud (1908) 
 have demonstrated that it is always due to the same parasite, the 
 cpidermophyton inguinale; although very closely related to the 
 trichophytons, it differs from these botanically and through the 
 fact of its never invading the hairs. 
 
 The eczema marginatum of Hebra has its seat of predilection at 
 the inner aspect of the root of the thighs. It begins in this region 
 on one or both sides, as one or several nummular spots of a bright red 
 color, sharply outlined and pruritic; by their rapid growth, these 
 spots become confluent in circinate patches, with red circinate 
 borders, often finely vesicular or bordered by white lamellar scales. 
 Meanwhile, the center usually fades or remains pigmented, inter- 
 spersed with scanty scales and excoriations, or with small crusts 
 due to scratching. Around the principal patch, secondary patches 
 often originate on the thighs, as far down as the knees, on the pubis 
 or the buttocks, taking the same course and sometimes involving 
 very extensive surfaces. On the scrotum and penis the lesions are 
 less distinct, almost obliterated. The eruption may spread to the 
 axillae, the submammary folds, the legs and feet; not infrequently 
 it coincides with epidermophytosis of the extremities; unless 
 properly treated, it may last for months and years. 
 
 Not uncommonly, especially in men and more particularly in the 
 well-to-do classes, eczema marginatum is contagious through sexual 
 intercourse and also indirectly through water-closets or underwear; 
 as a matter of fact, small epidemics are observed in colleges, work- 
 shops, asylums, etc. [The "jock-strap," the hired bathing suit, 
 etc., are common sources of infection.] 
 
 Microscopical examination of the scales — which must always be 
 taken from the red border — shows an abundance of mycelium 
 composed of quadrangular or sometimes ovoid elements, resembling 
 that seen in Fig. 161. Cultures grown on test media are radiating, 
 powdery, of a lemon yellow color, or downy through pleo- 
 morphism. 
 
 Eczema vulgare is distinguished from epidermophytosis by its 
 frayed margins and its less restricted localization ; intertrigo, by its 
 symmetry and its diffuse margins; erythrasma, by its relatively 
 stationary behavior, its dry finely scaly surface, of a uniform dusky 
 pink color, without vesiculation of the margins; the mycelium of the 
 microsporon minutissimum is infinitely more slender than that of 
 the epidermophyton (compare Fig. 161 and Fig. 166). 
 
 Epidermophytosis is differentiated from herpes circinatus tricho- 
 phyticus by its predilection for the covered regions, by its tendency 
 to become confluent in polycyclic surfaces or in arabesques; the 
 patches are not invariably disks or closed circles, but are sometimes 
 open on one side. The demonstration of the invasion of the downy 
 
526 PARASITIC DERMATOSES 
 
 hairs, or cultures of the parasite, may he required in support of the 
 diagnosis, but the matter is of no particular importance. 
 
 Treatment by painting daily with iodin tincture diluted with three 
 or four parts of 80 per cent, alcohol, is usually sufficient; if neces- 
 sary, it may be supplemented by the employment of a zinc salve 
 with oil of cade (5%) and salicylic acid (1%). [Whitfield's oint- 
 ment, Ac. Salicyl. 1.0, Ac. Benzoic. 2.0, Petrolati, 15.0 is most 
 valuable.] Chrysarobin ointments are also very effective, but 
 involve the risk of a severe and painful dermatitis. 
 
 Epidermophytosis of the Extremities. — The same epidermophy- 
 ton inguinale — as discovered by Sabouraud in 1910 — is the patho- 
 genic agent of a very common affection of the interdigital spaces of 
 the feet, which was formerly confused with eczema, dysidrosis, 
 intertrigo, or maceration due to hyperidrosis of this region. 
 
 The lesions chiefly occupy the floor of the interdigital folds, 
 especially between the fourth and fifth toe and the flexion folds of 
 the toes. A macerated horny layer is present and becomes detached 
 in the form of white shreds, leaving a bright red surface or a cheesy 
 material; in the circumference a few vesicles are sometimes seen, 
 which may dry or coalesce into an eczematiform surface. This dry, 
 vesicular or impetiginous parasitic eczema may extend to the dorsal 
 aspect of the foot as well as to the sole, even encroaching upon the 
 plantar arch as far as the heel. With remissions and exacerbations 
 the disease may be prolonged for many years or indefinitely. 
 Through the itching induced by it, the burning sensations and 
 superadded pyodermatitis, it becomes a source of distress, interferes 
 with the wearing of shoes and may make prolonged walking impos- 
 sible. Failure to recognize this dermatosis has often caused the 
 patients to be subjected to strict diets, cures in watering-places, etc. 
 
 On the hands and fingers, epidermophytosis is likewise met with, 
 although much less frequently, in the form of vesicular lesions or 
 squamous, rarely circular exfoliations of the palmar surfaces; it is 
 almost invariably confused with a dysidrosis. 
 
 Epidermophytosis of the extremities is accordingly eczematiform 
 or dysidrotiform rather than like the palmar and plantar trichophy- 
 tosis. Microscopic examination is necessary to establish a positive 
 diagnosis; the mycelium is abundantly present in the scales. Cul- 
 tures arc difficult on account of bacterial contaminations. 
 
 Treatment. — The treatment is the same as that of inguinal mar- 
 ginate eczema, but in view of the thickness of the horny layer, the 
 action of the dilute iodin tincture must be reinforced by moist 
 dressings during the night, followed by careful scraping and cleans- 
 ing. Sabouraud recommends an ointment of lard and chrysarobin 
 (1 to 3 to 100) with salicylic acid (5 to 100), avoiding all washing 
 with soap and water. [In my experience, a five-day course of 
 i)reuw's ointment is incomparably the most effective treatment.] 
 
EPIDERMOMYCOSES 527 
 
 Microsporia. — The parasite of tinea tonsurans with small spores, 
 the microsporon (p. 421), was discovered by Gruby, then misinter- 
 preted, lost, and re-discovered by Sabouraud in 1892. It differs 
 from the trichophytons in its microscopical and botanical features 
 and in the appearance of the lesions produced by it. The contri- 
 butions of Adamson, C. Fox and Blaxall, Bodin, etc., and especially 
 the work of Sabouraud, collected in his book on The Tineas, 1910, 
 have definitely settled the scientific data concerning it. 
 
 The microsporon Aiidouini — the first discovered, which infests 
 especially Northeastern Europe, is at the present time endemic in 
 England, causes two-thirds of the cases of microsporic tinea ton- 
 surans in Paris and is responsible for the epidemics in children's 
 asylums and schools — is now known to be not the only species met 
 with in man. 
 
 There are about ten other microsporons which are for the most 
 part of direct or indirect animal origin (m. lanosum or caninum, m. 
 felinum, m. equinum) and give rise in nearly all countries of the 
 earth to sporadic cases or small family epidemics. 
 
 The microscopical demonstration and the culture of micro- 
 sporons are the same as those of the trichophytons. Cultures of 
 the microsporon Audouini, on the maltose medium of Sabouraud 
 and at room temperature, become visible on the fifth day, measure 
 5 cm. at the end of a month and resemble a layer of white or grayish 
 short-nap wool. Cultures of microsporons of animal origin are of 
 quicker growth and more downy, their fluff showing abundant 
 multilocular spindles under the microscope; furthermore, the last- 
 named cultures undergo from the fifth week on a downy pleomorphic 
 degeneration, not shown by cultures of the microsporon Audouini. 
 
 Microscopical examination of microsporon cultures shows modes 
 of reproduction akin to but different from those of achorions and 
 trichophytons, in the form of pyriform swellings on the filaments, 
 large spindle-shaped and partitioned conidia, pectinate hyphens, 
 clusters of cylindrical and sessile conidia, etc. 
 
 The microsporon Audouini affects exclusively the scalp of chil- 
 dren, where it causes the microsporic tinea which has been described 
 elsewhere in the work (XX). 
 
 It very rarely vegetates on the hairless skin, where it produces 
 scaly pinkish spots of ephemeral character and self-limited duration. 
 
 Animal microsporons outside of the hairy scalp and even in adults 
 sometimes cause erythemato-squamous, nummular or circinate, 
 pink or dun-colored spots, in large numbers, exceptionally even 
 generalized over the entire body. These spots of cutaneous micro- 
 sporosis may last a month and a half. A few cases of microsporic 
 sycosis of the beard have been observed in men. 
 
 In the scales of tinea tonsurans with small spores, or in those of 
 
528 PA RA 81 TIC DERMA TOSES 
 
 epidermic microsporosis, examination in potash solution shows 
 abundant twisted and serpentine filaments, with apparently few 
 partitions, frequently bearing small lateral protuberances. After 
 staining, this mycelium appears divided into septa at short intervals. 
 
 Tropical Epidermomycoses. Tokelau or Tinea Imbricata. — This 
 dermatosis is endemic in the islands of the Pacific and in Indo-( 'hina. 
 It is observed in natives of all ages. 
 
 The disease, which persists throughout life, manifests itself as 
 regular erythemato-squamons concentric circles. The shell-like 
 scales are adherent at their peripheral portion, loose at their central 
 portion and overlap like the tiles of a roof. The circles and their 
 underlying patches increase in number and size, become interrupted 
 through a variety of factors, until the entire integument becomes 
 covered with squamous arabesques, including the face, the extremi- 
 ties and the nails, but not including the scalp. The patient roughly 
 resembles a case of ichthyosis; he suffers from severe and continuous 
 pruritus. 
 
 The microscope shows a dense network of branching and spore- 
 bearing mycelium in the scales; the condition is referred by Manson 
 to a trichophyton capable of inoculation from man to man but 
 not growing in cultures, namely the trichophyton concentricum of 
 Blanchard; Tribondeau describes the organism as aspergillus 
 lapidophyton. Castellani reports successful cultures and inoculations 
 of endodermophytons. 
 
 Carates and Central A merican Epidermomycoses. — Under the name 
 of carates, mat del Pinto, or Pinta, are designated numerous epidermo- 
 mycoses due to chromogenic parasites, widely distributed in tropical 
 America and although known for a long time, as yet inadequately 
 studied. They are characterized by spots which become confluent 
 in large desquamating lobulated patches and may become general- 
 ized. There exists a black, blue, violet, red, yellow and a white 
 variety; all, except the red one, may ultimately turn white. The 
 odor is offensive, the hairs fall out, the nails remain intact. Asso- 
 ciation with scabies is common. The scales enclose a profuse tangle 
 of mycelium. The chromogenic parasites, studied by Montoya, 
 belong to the groups of aspergillus, penicilium, monilia, montoyella, 
 microsporon and trichophyton. 
 
 Aside from these carates, various imperfectly known epidermo- 
 mycoses are met with in Central America, which give rise to red 
 patches covered with white scales, sometimes hyperkeratotic, with 
 polycylic contours; they may attack the nails and are of indefinite 
 duration. In a case (Fig. 163) observed by me in a patient from 
 Ecuador, published in 1903, the scales enclosed a network of a 
 mycelium which Bodin (of Rennes) successfully grew in cultures; 
 he found it to be related to trichophytons and still more closely to 
 
EPIDERMOM YCOSES 
 
 529 
 
 the lophophyton gallinse, the parasite of chicken-favus, which 
 causes the "white comb" in fowls. There are probably more or less 
 analogous epidermophytoses due to various fungi in many tropical 
 countries. 
 
 The treatment of these exotic mycoses is extremely tedious. I 
 have obtained the best results with chrysarobin in ointments (of 1 
 to 3 per cent.), or in varnishes like traumaticine. 
 
 Fig. 163. — -Central American epidermomycosis of seven years' standing, diagnosed 
 as carate; note the lesions of the nails and genital organs. The patient suffered at the 
 same time from scabies. 
 
 Pityriasis Versicolor. — Pityriasis versicolor is a parasitic affection 
 of the epidermis, characterized by yellowish and scaly spots, caused 
 by the microsporon furfur or malassezia furfur. 
 
 Confused by the ancients with pigmentary spots, pityriasis 
 versicolor was distinguished from these by Willan, who classified 
 it among the squamous diseases and gave it the name it bears. 
 Eichstedt, in 1846, discovered the parasite, which was christened by 
 Ch. Robin. 
 
 Pityriasis versicolor manifests itself as sharply defined patches, 
 varying in color from a dirty yellow, tan or chamois to a dark brown, 
 sometimes with an admixture of a pinkish shade. The color varies 
 in different persons, different regions, and even on the same spot at 
 different times; hence the name of versicolor. In the colored races, 
 the spots are lighter than the normal skin and achromic by contrast. 
 
 The spots are slightly scaly, powdery or entirely smooth. Their 
 34 
 
530 PARASITIC DERMATOSES 
 
 essential feature, however, is that the horny epidermis is here less 
 adherent than under normal conditions, so that on vigorous scratch- 
 ing with the nail a desquamated shred becomes detached without 
 bleeding. This "nail-scratch or flake sign" is almost pathognomonic 
 and is due to the fact that the presence of the parasite permits the 
 superficial horny layers to slide over the deeper layers. 
 
 The spots are not prominent. Their shape and dimensions are 
 extremely variable. They may be punctate, guttate, in disks, 
 rings or patches, or cover large surfaces with geographical contours, 
 sometimes involving a large portion of the thorax; these various 
 configurations are often seen on the same individual. 
 
 Any region of the integument may be the seat of pityriasis versi- 
 color, with the exception of the hands and feet. Its seat of election 
 is the upper part of the chest, in front and behind, whence it reaches 
 the shoulders, the flanks, the abdomen, the groins, the arms and 
 rarely the legs. It is exceptionally observed on the neck, the chin 
 and even on a large portion of the face. 
 
 The growth of the vegetating parasite as a rule causes no itching 
 at all, so that the patients are not aware that they are affected with 
 a parasitic dermatosis. The duration of the disease is always very 
 protracted and indefinite; it may, however, heal spontaneously, 
 for it is never met with in the aged. It progresses and becomes 
 aggravated under the influence of sweating and in the absence of 
 ablutions and remains stationary under contrary conditions. 
 
 Microsporon furfur grows exclusively in the horny layer and pro- 
 duces no inflammatory reaction. It never invades the hairs. In 
 the shreds detached with the finger-nail may be seen (after clearing 
 with potash and under a magnification of 300 diameters) numerous 
 clusters of fifteen to thirty round spores, with double contours, 
 measuring from 3 to 5 /*. From these masses, radiating and inter- 
 laced mycelium filaments which traverse the intermediate spaces 
 are given off. They are winding, short, somewhat irregular, slightly 
 branching, divided by septa and in places spore-bearing (Fig. 164). 
 
 The culture of microsporon furfur, remarkably enough, meets 
 with great difficulties; successful cultures were grown by Mat- 
 zenauer and Nicolle, the latter using glycerin-agar. 
 
 The etiology naturally depends upon the transmission of the 
 parasite. But pityriasis versicolor is very slightly contagious; it 
 is rare for husband and wife to infect each other or to convey the 
 contagion to their children. Kobner after many attempts succeeded 
 in inoculating himself and in infecting rabbits. The incubation 
 lasts over a month. 
 
 This epidermomycosis is common among adolescents and adults 
 of both sexes; it is very rarely seen at an early age. In all prob- 
 ability it requires special regional conditions. The influence of a 
 
EPIDERMOM YCOSES 
 
 531 
 
 tuberculous soil has been exaggerated; for some time, a relation 
 between the microsporon and the agent of tuberculosis was erro- 
 neously surmised. The frequent coincidence is probably accounted 
 for by the sweating of consumptives, the habitual wearing of 
 flannels and the fear of bathing. 
 
 The diagnosis is based essentially upon the "flake sign;" a 
 microscopical examination is almost superfluous. If only the phy- 
 sician will think of looking for this sign, a confusion with congenital 
 pigmentary spots, chloasma, pigmentary syphilides, eczematides, 
 etc., is impossible. The distribution of certain pigmentary spots of 
 leprosy may be analogous to that of pityriasis versicolor. 
 
 Fig. 164. — Microsporon furfur in a scale from pityriasis versicolor; stained with 
 Sahli's blue. X 325. 
 
 Although common pityriasis versicolor may occur, as I have 
 myself seen, among the inhabitants of Annam and Cambodia, 
 there is in addition a tropical pityriasis versicolor, or tinea flava, or 
 parasitic achromia with estival exacerbations (Jeanselme). This 
 epidermomycosis is very common in the far Orient and is character- 
 ized by yellowish, slightly scaling spots which preferably occupy 
 the face, neck and upper trunk, is of very slow development and 
 difficult to cure. It is caused by malassezia tropica (Castellani, 1905) 
 which has a short, swollen or club-shaped mycelium with spores 
 not always arranged in clusters. 
 
 The treatment of pityriasis versicolor must aim at removing 
 the horny layer which alone harbors the parasite. Not a spore 
 must be left behind, so as to guard against recurrence; on the 
 other hand, unnecessary irritation must be avoided. Tincture of 
 iodin, employed as in herpes circinatus, lard with chrysarobin 
 (1 to 1000), or simply soft-soap rubbed on for ten minutes followed 
 
532 
 
 PARASITIC DERMATOSES 
 
 by a bath, arc usually sufficient. For regions where the skin is 
 sensitive, in the groins or in the axillae, recourse may be had to 
 naphthol (1 to 30) or sulphur (1 to 20) salves and to salicylic acid 
 ointments (1 to 30), not forgetting washes with soap and baths, as 
 well as disinfection of the body linen. [A simple and effective treat- 
 ment consists in a daily bath with soap followed by a sponging with 
 a 1 to 8 solution of photographers' Hypo for a week; the course of 
 treatment, whatever it may he, should he repeated after two weeks' 
 interval.] 
 
 Erythrasma. The practitioner is usually not so well acquainted 
 with this disease, although it is as common as pityriasis versicolor; 
 it is an epidermomycosis due to the microsporon minutissimum and 
 appears in the form of brownish or yellowish-pink patches especially 
 in the inguinal folds. 
 
 Fig. 165.— Erythrasma 
 .somewhat more extensive 
 i um of Hebra. The micrc 
 iMUT (,!' microsporon miimt 
 
 The territory occupied by the epidermomycosis was 
 um usual in this case, which resembles eczema margina- 
 lope showed the abscess of epidermophyton and the pres- 
 
 Erythrasma is found in adult or old men, of all social classes, much 
 more rarely in women and never in children. 
 
 Its origin always escapes attention; the patients are usually 
 unaware of having it and are ignorant of its onset. Subjective 
 symptoms are absent; sometimes moderate itching is noted after 
 sweating. The course is very slow; the duration is indefinite. 
 
 The seat of election of this dermatosis is in the genitocrural fold 
 high up on the internal aspect of the thigh (Fig. 165); it rarely 
 encroaches upon the pubis and the scrotum. The lesions are uni- 
 lateral or bilateral. Much more rarely the axillae are also involved. 
 
 The erythrasma patch, ordinarily from 5 to 12 cm. wide in all 
 diameters has an always distinct, polyeyclic and serrated circum- 
 
EPIDERMOMYCOSES 533 
 
 ference; outside of the principal patch, small islands of the same 
 character may be found on the thighs, the abdomen and elsewhere, 
 but this is altogether exceptional. The color is uniform as a rule 
 but very variable according to the moment when seen, dark red, 
 deep yellow, brownish with a tinge of pink. The surface is level, 
 powdery, finely squamous, and often criss-crossed in very fine folds. 
 It is oily and moist during perspiration. 
 
 Examination of the scales under the microscope, with a magnifi- 
 cation of 400 diameters, after treatment with potash solution, 
 serves to demonstrate the parasite in some cases, but not easily. 
 It is better, after removing the fat with ether, to stain the scales 
 with Sahli's blue or with phenol-thionine (Fig. 166). 
 
 
 
 
 Fig. 166. — Microspores minutissimum in a scale of erythrasma. Stained with 
 Sahli's blue. X 1000. 
 
 This parasite is the microsporon minutissimum, or discomyces 
 minutissimus , discovered by Burchardt in 1859. It appears in the 
 form of very fine filaments, less than 1 n wide, twisted and branching, 
 apparently fragmented and provided with spores at their extremi- 
 ties. These filaments are extremely abundant and constitute a real 
 network between the horny cells. Culture of the discomyces is 
 difficult; but Michele, Ducrey and Reale seem to have obtained it 
 and were able to inoculate it on man. 
 
 Erythrasma is very slightly contagious; it is rare for husband and 
 wife to be simultaneously affected. 
 
 Transmission possibly takes places through underwear, water- 
 closets, etc. 
 
534 PARASITIC DERMATOSES 
 
 The diagnosis is obvious in the majority of the cases, although 
 sometimes difficult. 
 
 Intertrigo is more inflammatory and has no sharply defined 
 contours. Eczematides are rarely so narrowly localized. Partial 
 prurigo is highly pruritic and lichenized. Inguinal epidermo- 
 phytosis is of a bright red color, is polycyclical and marginated, takes 
 a rapid course and has a much larger parasite. 
 
 The treatment is analogous with that of pityriasis versicolor 
 and inguinal epidermophytosis, but erythrasma is more rebellious. 
 In a few weeks an apparent cure is obtained, but great persever- 
 ance is needed in order to avoid a recurrence. [The interrupted 
 or discontinuous method of sterilization yields the best results 
 in this as in many other infectious diseases. In erythrasma as in 
 pityriasis versicolor one week of treatment should be followed by 
 two weeks of rest, and several courses of treatment are usually 
 necessarv.l 
 
CHAPTER XXjVI. 
 INFECTIOUS DERMATOSES— PYODERMATITIDES. 
 
 In the following chapters (XXVI to XXIX) I shall discuss the 
 infectious dermatoses whose parasitical agent is established, known 
 and specific, or practically specific. 
 
 Some are referable to internal infections, such as syphilides, the 
 rose-spots of typhoid fever, of some tubercular eruptions, etc. 
 
 Others are due to external infections, like the pyodermatitides, 
 soft chancre, some cutaneous tuberculoses, Biskra boil, etc. 
 
 The following review, however, by no means exhausts the question 
 of the part played by infections in skin diseases. 
 
 For many eruptions the causative infectious agent is still unknown 
 (example: eruptive fevers); or it is not specific, in the sense that 
 different microbic species may lead to the same syndrome (examples : 
 purpura, ulcers, multiple gangrenes, elephantiasis) ; or it is secondary, 
 superadded, perhaps accessory (examples: eczema, artificial der- 
 matitides, etc.). 
 
 Finally, in many cases, the role of an infectious agent is theo- 
 retical, suspected or vaguely surmised (examples: polymorphous 
 erythema, secondary and primary infectious purpuras, primary 
 erythrodermas, warts, vegetations, pemphigus, acute nodosities, 
 molluscum contagiosum). 
 
 According to the plan here adopted, these various syndromes 
 figure only in the first part of this work, which is devoted to the 
 morphology of skin diseases. In this part only pathological entities 
 with an established infectious etiology are considered. 
 
 These infectious dermatoses, according to the nature of their 
 pathogenic agent, may be classified as follows : 
 
 1. Infectious dermatoses caused by cocci: these are the pyo- 
 dermatitides, to be discussed first of all. 
 
 2. Dermatoses caused by bacilli, or infectious bacillary dermatoses 
 (XXVII). 
 
 3. Infectious dermatoses caused by vegetable parasites of an 
 order higher than the cocci and bacilli: dermatomy coses (XXVIII). 
 
 4. Infectious dermatoses due to protozoa: spirochetes, leishmanias, 
 etc. (XXIX). This group comprises syphilis and a few more or less 
 analogous exotic dermatoses. 
 
536 INFECTIOUS DERMATOSES— PYODERMA T I TIDES 
 
 PYODERMATITIDES. 
 
 The acute inflammations of the skin due to the ordinary microbes 
 of suppuration or pyococci are called pyodermatitides. 
 
 Pyococci. — The vast majority of suppurations of the skin are 
 caused by two groups of microbes: staphylococci and streptococci. 
 In each of these groups numerous varieties or species are distin- 
 guished which are interpreted by some bacteriologists as simple 
 strains. These varieties differ from each other in their morphology, 
 their cultural characteristics, their habitat and — what is especially 
 of clinical interest — in their virulence. 
 
 Staphylococci are cocci of somewhat variable size, which appear 
 in pus in the form of diplococci, or in a series of three or four granules; 
 in cultures they are arranged in masses or clusters. 
 
 They grow readily on most of the ordinary artificial culture media, 
 preferably at 37°; they have a variable chromogenic capacity which 
 is the basis of a differentiation between the cocci obtained from the 
 pus, as follows: Staphylococcus aureus, Staphylococcus albus, Staphy- 
 lococcus citreus, etc.; they liquefy gelatin more or less rapidly; 
 they possess a high degree of vitality. 
 
 Nearly all staphylococci are pyogenic; on inoculation they pro- 
 duce subcutaneous abscesses, peritonitis, etc., in the majority of 
 animals. When injected into the ear-vein of rabbits, they give rise, 
 according to dosage and virulence, to a rapidly fatal septicemia, 
 miliary abscesses of the kidneys, arthritis, osteomyelitis, endo- 
 carditis, etc. Garre, Bockhart and Rodet produced folliculitis, 
 impetigo, furuncles, etc., by rubbing cultures upon the human skin. 
 
 Up to ten varieties or species of staphylococci have been described. 
 One of great importance on account of its abundance on the skin is 
 designated under the names of Staphylococcus cutis communis, or 
 Coccus iwlymorphis of Cedercreutz. This microbe, which undoubt- 
 edly corresponds to the morococcus of Unna, presents itself in the 
 scaly crusts of eczematides under the aspect of mulberry-shaped 
 clusters; it groAvs on glycerin-agar in porcelain-gray streaks or 
 drops and gives off a butyric odor. It does not liquefy gelatin. It 
 is usually considered as non-pathogenic, but its inoculation on the 
 human skin has been known to cause folliculitis or small vesicles of 
 eczema. 
 
 Staphylococci are widely distributed in the air, in dust and in 
 water; they are regularly present in the mouth, at the natural 
 orifices, and are disseminated on the skin. 
 
 Streptococci are cocci arranged in small chains of variable 
 length, often composed of diplococci; the size of the granules 
 varies. Streptococci will grow on all ordinary culture media, pref- 
 erably under anaerobic conditions; the optimum temperature is 
 
PYODERMATITIDES 537 
 
 37°. They do not liquefy gelatin and form flakes in broth-cultures; 
 their vitality is readily destroyed by the air. In order to isolate a 
 streptococcus contaminated with other cocci, Sabouraud recom- 
 mends growing the first culture in a pipette in bouillon or ascites- 
 fluid; or, according to a familiar procedure, the suspected material 
 may be planted on several slanting tubes of peptone-agar and 
 numerous streak-cultures planted without recharging the platinum 
 needle. 
 
 The virulence of different streptococci varies to an enormous 
 extent. The streptococcus of erysipelas, discovered by Fehleisen, the 
 Streptococcus pyogenes of Ogston and Rosenbach and the strepto- 
 coccus of puerperal infection, undoubtedly belong to a single species. 
 As regards other varieties, differing in their morphological and bio- 
 logical features as well as their habitat, the question has not yet 
 been settled. 
 
 On inoculation into a rabbit's ear, a very virulent streptococcus 
 gives rise to fatal septicemia; a less virulent germ causes erysipelas; 
 a still weaker one will produce an abscess. By means of intravenous 
 injections into animals, practically all the affections caused by 
 streptococci in human beings have been successfully reproduced. 
 
 Streptococci have their ordinary habitat in the air, in the ground, 
 on the skin and especially in the mucous cavities. They are less 
 frequent on the epidermis than staphylococci, but are constantly 
 present in the mouth of healthy individuals. 
 
 The relations existing between the Streptococcus pyogenes and the 
 Streptococcus of the saliva (Veillon), the Streptococcus of scarlet 
 fever, the small granular streptococcus, those which liquefy gelatin 
 or are encapsulated, etc., have not been definitely established. Up 
 to 46 species have been described (Gros). 
 
 Other microorganisms in large number, but not properly speaking 
 pyococci, are likewise more or less commonly encountered on the 
 skin and in the surroundings of the natural orifices, such as : various 
 micrococci; the bacillus of seborrhea, epidermidis, cutis commune, 
 subtilis fluorescens, coli, pseudodiphtheriticus , the bottle-bacillus or 
 Malassez spores, etc.; furthermore, a sarcina, a leptothrix, various 
 saccharomyces, etc. 
 
 The germs of the skin vary enormously in number according to 
 circumstances. The average is assumed to be 40,215 per square 
 centimeter; from 85 millions to 1212 millions of germs are left in a 
 bath, according to Remlinger; they flourish with especial luxuriance 
 in the moist and hairy regions of the body. Sabouraud has shown 
 that they are more abundant around pathological lesions of any 
 kind. Their principal receptacles aside from the mucous orifices 
 are the follicular funnels which constitute both a shelter for the 
 germs and the weak point in the epidermic armor (Chapter XIX). 
 
538 INFECT 10 US DERMA TOSES—P Y ODER MA TI TIDES 
 
 It must be understood that no scrubbing or ever so careful and 
 prolonged disinfection can be relied upon to remove or destroy all 
 the microbic inhabitants of the epidermis. With special reference 
 to pyodermatitis, it may be said that the seeds are practically 
 ubiquitous. However, the absence of cleanliness, contact with con- 
 taminated individuals, with soiled clothing or other articles, will 
 naturally greatly increase the chances of infection. 
 
 Pathogenesis. — In this respect, four points require attention: the 
 portal of entry, the virulence, the resistance of the soil and the patho- 
 genic mechanism. 
 
 A. The portal of entry of pyogenic microbes is external in the 
 vast majority of the cases. It is only in the pyemias, etc., that they 
 reach the skin by the vascular route, giving rise to intra- or sub- 
 dermic abscesses. 
 
 The protective barrier formed by the horny layer is removed 
 through traumatisms of all kinds, by parasitis such as sarcoptes or 
 lice and by scratching in case of pruritus. It is likewise impaired 
 by maceration or chemical lesions of the epidermis, such as those 
 caused by poultices, plasters and strong antiseptics like bichloride 
 of mercury, carbolic acid, etc. It is noteworthy that the latter are 
 usually more injurious for the epidermis than for the germs con- 
 tained in it, thereby favoring the propagation of the pyodermatitis. 
 The present tendency therefore is to replace the antiseptic dressings, 
 which were so popular in the past, by aseptic dressings. 
 
 The reason why the follicular orifices so often become the portal 
 of entry of infection is that they are usually already inhabited by 
 germs and on the other hand are easily damaged by friction, move- 
 ments, etc. Preexisting lesions of the epidermis, eczematization, 
 vesicles and bulla 3 , offer a ready-made culture-medium for the 
 pyococci; secondary infection, superadded suppuration or impetigi- 
 nization is therefore extremely common. 
 
 It is often difficult to estimate the relative significance of the 
 primary cause and of the secondary infection, as a matter of fact, 
 various chemical substances and certain specific microbes may be 
 pyogenic in themselves. 
 
 B. The degree of virulence of the parasites, pyococci and others, 
 is extremely variable, not only according to the species or strain, but 
 in the same strain. Some behave like simple saprophytes; others 
 again are highly pathogenic. The virulence of a microbe may be 
 attenuated or exalted by different laboratory procedures. Clinically, 
 it is governed by conditions not all of which have been established; 
 the best known although not the only cause of increased virulence is 
 primary growth in a pathogenic focus, the effect being comparable 
 to the well-known increased virulence by passage through an 
 animal; it accounts for the auto-inoculations, the contagiousness 
 
PLATE II 
 
 BOCKHARDT'S IMPETIGO (X 10) 
 
 MPETIGO OF TILBURY FOX (X 12) 
 
 Schematic Comparison of the Pyodermatitid.es. 
 
 Pus and necrotic tissues are shown in yellow ; the dots indicate 
 approximately the relative abundance of polynuclears in the epidermis 
 and in the cutis. The amplification is stated with the name of each 
 variety. 
 
PYODERMATITIDES 539 
 
 and persistence of some pyodermic lesions. A very considerable 
 number of common microorganisms are actually under suspicion, 
 being capable of assuming pathogenic properties under a variety of 
 circumstances. 
 
 C. The resistance of the soil against pyococci is also extremely 
 variable. Although immunity against them, either temporary or 
 permanent, does not exist, the susceptibility is evidently increased 
 under certain conditions. In children and youthful individuals, 
 such conditions are represented by the so-called lymphatic consti- 
 tution or scrofulous diathesis, by undernutrition, general weakness 
 and convalescence from disease. In adults, overexertion, general 
 nutritional disturbances, such as diabetes and cachexia, likewise 
 create a predisposition for pyodermatitides. The part played by 
 local circulatory disturbances or nutritional disturbances of the skin 
 manifests itself for example in varicose limbs. These factors explain 
 not only the easy onset of superficial pyodermatitides but also 
 their multiplication, their liability to recurrence, their obstinate 
 character and the tendency to complications with lymphangitis, 
 abscesses, adenitis and to termination in the grave forms of staphy- 
 lococcia and streptococcia which may lead to death in weakly 
 children and cachectic individuals. 
 
 D. Staphylococci and streptococci both possess, undoubtedly 
 due to their secretions, a vasodilator action and an attraction for 
 leukocytes known as positive chemotaxis. Under their influence the 
 skin becomes congested and the white corpuscles swarm into the 
 cutis, or, according to the case, into the epidermis, together with a 
 certain amount of plasma. Certain differences are noted, however, 
 between the properties of the two groups of pyococci. 
 
 The staphylococci attract especially the polynuclears and pro- 
 duce the smooth, creamy, thick pus which was formerly described 
 as "laudable pus." The streptococci are in a general way less 
 pyogenic; they give rise rather to an outflow of plasma and the 
 secretion of a turbid serous fluid or of thin serous pus. However, 
 according to Jadassohn, staphylococci may also give rise to serous 
 bullae. The Staphylococcus aureus, moreover, possesses necrotizing 
 properties, as shown by the core of furunculus and the slough of 
 carbuncle. Mixed infection produces intermediate effects. 
 
 Clinical Forms. — A series of pathological types is referable to the 
 penetration of pyococci into the epidermis, into the pilosebaceous 
 follicles, or into the cutis. I have endeavored to convey an idea of 
 the principal types in the subjoined schematic figures (see Plate II). 
 
 Among the staphylococcic pyodermatitides of external origin, I 
 have already described Bockhardt's impetigo, impetiginous eczema, 
 ostiofollicular pustules and deep folliculitis, sycosis, etc. Furun- 
 culus, carbuncle and hidrosadenitis will be discussed further on. 
 
540 INFECTIO I >' DERMA TOSES -PYODERMA Tl TIDES 
 
 Abscesses, diffuse phlegmons [cellulitis] and suppurating wounds 
 belong to the domain of surgery. 
 
 Staphylococci brought to the skin by way of the blood give rise 
 to multiple and successive emoblic abscesses, as one of the mani- 
 festations of pyemia, which is accompanied by grave general 
 disturbances. 
 
 I have previously had occasion to state that the miliary abscesses 
 of little children are not referable to the last named pathogenesis, 
 as formerly believed to be the case, but that they are the result 
 of an ascending infection of the sudoriparous canals. 
 
 I repeat that an association of various pyococci may be held 
 responsible for impetigo vulgaris and ecthyma (pp. 165, 169), for 
 various ulcers (XV), probably for pustular acne (p. 386), the microbic 
 eczemas (p. 66) and the eczematides (p. 97), as well as for 
 impetiginous onyxis (p. 434). 
 
 Referable to cutaneous streptococci a are: the impetigo of Tilbury 
 Fox, ecthyma, leg ulcer, erysipelas (which is not usually considered 
 in the scope of dermatology), the lymphangitides, lymphangitic 
 abscesses, phlegmons and adeno-phlegmons, which belong to the 
 domain of surgery. 
 
 Perleche. — Perleche — a very trifling affection, interesting on 
 account of its contagiousness and the diagnostic errors which it 
 occasions — consists of a circumscribed redness of the two labial 
 commissures, with maceration of the epidermis and often fissure- 
 formation. It is frequent in children who contract it in school and 
 transmit it to the family; it may last for weeks and months. Some- 
 times it coexists with impetigo vulgaris or impetiginous stomatitis. 
 
 Perleche seems to be a simple regional streptococcia. By J. 
 Lemaitre, who described it in 1886, it was attributed to a so-called 
 Streptococcus plicatilis, which is probably in no way specific. 
 
 A differential diagnosis must be made from herpes, which is 
 rarely bilateral and always vesicular at the onset; and especially 
 from mucous patches, but these are accompanied by other manifes- 
 tations of secondary syphilis. 
 
 Perleche is treated like impetigo. Silver nitrate, Alibour water, 
 yellow precipitate ointment, or steresol, etc., will promptly check 
 it. The children must not be allowed to kiss and their glasses and 
 tableware should be washed in boiling water. 
 
 Finally, there occurs nonsuppurative manifestations of the various 
 pyococcias, such as certain purpuras (Chapter III), probably botryo- 
 mycoma (p. 704) and perhaps the necrotic and keloid forms of acne, etc. 
 
 Furunculus. — A furuncle or boil is a massive folliculitis with a 
 usually very acute inflammatory course and necrotic character. 
 Boils are due to the Staphylococcus aureus, as discovered in 1880 
 
PYODERMATITIDES 541 
 
 by Pasteur, who soon afterward was able to demonstrate the 
 "microbe of furuncle" in osteomyelitis. 
 
 Whether it be derived from a contagion, or what is more common, 
 from auto-inoculation of another staphylococcic lesion, the microbe 
 must necessarily have been introduced rather deeply into the follic- 
 ular canal in order to produce a furuncle. Hence, boils preferably 
 develop in regions exposed to rubbing from clothes or implements of 
 work; they are common in rag-pickers, refiners, mechanics, riders, 
 etc. Fatigue, nervous disturbances, errors in diet and convalescence 
 from acute diseases are predisposing factors. Diabetes mellitus 
 especially constitutes such a favorable soil that the urine should be 
 examind as a routine procedure in all cases of furunculosis. 
 
 In certain individuals, through the effect of a very marked pre- 
 disposition or rather because immunization does not occur as under 
 normal conditions, boils follow one another for a period of months 
 and years. This furunculosis may be connected with a run-down 
 condition, auto-intoxications, etc.; but its cause often remains 
 undemonstrable. 
 
 A furuncle begins with a red acuminate elevation with a hair in 
 its center; its two essential features are induration and pain. There 
 is often considerable edema of the vicinity. In three to five days, 
 the growing protuberance has assumed a purplish, later pustular 
 apex. Having reached maturity, the furuncle softens and opens; 
 after a flow of pus, a core or slough is eliminated, consisting of 
 necrotic cellular tissue infiltrated with pus. The pain subsides as 
 soon as the discharge of pus is freely established. 
 
 A furuncle always leaves a more or less visible cicatrix, unless it 
 has been aborted, spontaneously or as the effect of treatment; in 
 this case, the induration lasts from three to twelve days and finally 
 becomes absorbed. In weakened or diseased persons, boils are 
 accompanied by extensive edema, fever, malaise, etc. 
 
 Boils may be situated wherever there are hair follicles, but the 
 site of election is at the nape of the neck; next in order follow the 
 back, the buttocks, the lower limbs, the forearms, etc. 
 
 Furuncle of the upper lip gives rise to a severe and very alarming 
 inflammatory tumefaction, and the possibility of lymphangitis, 
 phlebitis and meningeal complications must be borne in mind. 
 
 Furuncles of the auditory meatus are noteworthy on account of the 
 resulting pain, which is very severe, radiates widely, interferes with 
 mastication and prevents sleep. These furuncles are often asso- 
 ciated with auricular eczema; they have a tendency to recur and 
 may affect one ear after the other. 
 
 A furuncle differs from ordinary suppurative folliculitis by the 
 severity of the inflammatory reaction, the induration of the tissues, 
 the pain and the core or slough. It is distinguished from hidros- 
 
542 INFECTIOUS DERMATOSES— PYODERMATITIDES 
 
 adenitis, which moreover is practically limited to the axilla, by its 
 acuminate form and by its core. The differential diagnosis from 
 malignant pustule [anthrax] may, in exceptional cases, prove some- 
 wliat difficult. 
 
 Treatment. — At the onset, abortive treatment may be tried; for 
 this purpose, a finely pointed galvanocautery or thermocautery 
 needle may be inserted in the center of the furuncle, or it may be 
 painted twice, at an interval of twelve hours, with iodin tincture 
 or iodo-acetone. The adjacent skin should be cleaned with an 
 antiseptic soap and washed with camphorated or resorcinated alcohol. 
 
 In its developed stage, the furuncle must not be irritated by 
 strong antiseptics, which would cause a complicating artificial der- 
 matitis, without any benefit whatever. It suffices to make two daily 
 applications of a hot spray with weak carbolic, resorcin, or pheno- 
 salyl water, or simply washing with Alibour water; the parts are 
 then covered with cotton wadding, moist dressings with boiled water, 
 or still better with a layer of cotton covered with borated starch 
 glycerolate (1 to 10), which affords a better protection against 
 neighborhood inoculations. 
 
 I have never found it necessary to incise a furuncle. It would be 
 more justifiable to perform complete excision at the onset, provided 
 the patient and the locality permit. The pain caused by interstitial 
 injections, even with gaseous oxygen is not offset by their advan- 
 tages. In the period of repair, it is advisable to cover the orifice 
 with mercurial plaster or with yellow oxide of mercury salve or a 
 piece of gauze. 
 
 [An attempt to abort a boil by the accurate application of a solu- 
 tion of iodin to its apex, repeated three times with twelve-hour 
 intervals, should always be made at the inception of the process. It 
 is useless when there is already a considerable induration. In cases 
 of furunculosis every follicular inflammation, even the most insig- 
 nificant, should be regarded as suspect and treated abortively. I 
 agree with the author in condemning incision of a boil; it is bad 
 practise, painful and useless. I earnestly recommend the following 
 treatment: the affected area is washed with alcohol or 1 to 2000 
 bichlorid alcohol. The boil is then covered with a 3 to 4 cm. square 
 of salicylic acid plaster made according to the formula of Dr. 
 Klotz: 1$ empl. diachyli 00.0, empl. saponis 25.0, cerse 2.0, vaselini 
 8.0, acidi salicylici 5.0, M. ft empl. secundam artem. This plaster 
 mass rolled in sticks for convenience is spread as required, smooth, 
 even and thin on cotton-sheeting (muslin) and applied over the 
 boil. It is soothing, protective and sufficiently occlusive while not 
 adhering firmly enough to cause retention of pus. It should be 
 removed twice a day, the free pus very gently squeezed out, the 
 surface washed with a mild antiseptic and fresh plaster applied. In 
 
PYODERMATITIDES 543 
 
 cases of furunculosis I employ the stock vaccines, four or five injec- 
 tions at intervals of three to five days.] 
 
 Internal treatment, with colloidal sulphur, sulphuric acid lemon- 
 ade, sulphur compounds, hyposulphites, ichthyol, etc., is very 
 variably estimated. Beer-yeast, preferably fresh, in doses of three 
 tablespoonfuls daily, not infrequently produces a sudden subsidence 
 of the inflammation and the pain. When it fails, beer-yeast from 
 another source should be tried, or it may be replaced with a different 
 ferment, for example a lactic ferment. 
 
 In furunculosis the vaccine therapy of A. E. Wright, even with 
 a stock vaccine of Staphylococcus aureus, constitutes an excellent 
 although sometimes unreliable method of treatment. 
 
 Care must of course be taken to correct the patient's hygiene; 
 the dietetic regimen indicated in diabetes, auto-intoxication, arthri- 
 tism, etc., may be called for in some cases. A cure at watering 
 places with sulphur or arsenical springs is sometimes very useful in 
 obstinate cases of furunculosis. 
 
 Systematic treatment of furuncle, furunculosis and other staphy- 
 lococcias with pure metallic powdered zinc mixed with zinc oxide, 
 in doses of 4 to 8 grams daily, as recently introduced by Frouin and 
 Gregoire, is extremely simple and sometimes seemed to be efficient 
 in my experience. 
 
 Carbunculus.— Carbuncle (French, anthrax) may be considered as 
 an agglomeration of furuncles. The etiology is the same as that of 
 furuncle. Garre successfully produced a carbuncle through inocu- 
 lation of staphylococci derived from a case of osteomyelitis. 
 
 The lesions are more extensive than those of furuncle; the necrosis 
 of the perifollicular cellular tissue becomes confluent in large areas 
 which are finally detached by the suppuration and appear no longer 
 in form of circumscribed sloughs but under the aspect of sometimes 
 very extensive gangrenous shreds. 
 
 [The differences between carbuncle and furuncle are not simply 
 a matter of degree. The phlegmonous inflammation in furuncle 
 starting in a follicle always remains definitely circumscribed in a 
 globular form, with the follicle as its center, though it may extend 
 as far as the hypoderm. In carbuncle a similar infection extends 
 into the hypoderm and then spreads to a greater or less extent 
 laterally in the hypoderm ascending by the path of the columnae 
 adiposes to the surface where it appears as a group of secondary 
 furunculoid elevations in the neighborhood of the primary furuncle. 
 A carbuncle is always a grave affection because it is capable of 
 indefinite lateral extension in the hypoderm.] 
 
 The onset is often marked by chills, malaise, general prostration, 
 anorexia, while at the same time a very hard red swelling makes its 
 appearance, which is the seat of severe tearing pain. The neighbor- 
 
544 INFECTIOUS DERMATOSES— PYODERMATITIDES 
 
 ing edema is usually considerable and very extensive. At the end 
 of lour or five days a few small vesicles or pustules manifest them- 
 selves at the follicular orifices of the carbuncle; these become trans- 
 formed into openings or craters from which pus escapes in increasing 
 amounts and the grayish necrotic masses are subsequently evacu- 
 ated. The skin between the orifices is purplish and swollen, often 
 eroded; the bridges separating the orifices are often destroyed by 
 purulent disintegration or necrosis. The openings of a carbuncle are 
 accordingly multiple, irregular and winding. The period of evacua- 
 tion lasts from a fortnight to a month. Spontaneous pain ceases as 
 soon as the deep sloughing reaches its limit. Repair takes place by 
 granulation; it leaves a very noticeable, often retracted and stellate 
 cicatrix. 
 
 In weakened patients, or in diabetics, etc., the woody indura- 
 tion at the onset of a carbuncle may attain enormous proportions 
 (woody phlegmon of the aged). In the period of suppuration, enor- 
 mous winding cavities and purulent tracts are formed and sometimes 
 large gangrenous patches. These diffuse or malignant carbuncles are 
 accompanied by high fever, excitement, wild delirium or profound 
 depression; they may lead to death through septicemia, hectic 
 fever, or by rupture of large vessels or opening into large cavities. 
 
 The prognosis, which is very variable, would seem to depend 
 either on the virulence of the infection or on the character of the 
 soil. The duration of a moderately severe carbuncle is from a 
 month to six weeks. 
 
 The treatment of benign carbuncle is patterned on the treatment 
 of furuncle. Incision is rarely necessary or advisable. In large car- 
 buncles, the introduction of sticks of Canquoin's paste (therapeutic 
 notes, § 11) evidently shortens the total duration of the process. 
 The treatment of malignant carbuncle belongs to the domain of 
 surgery. 
 
 Hidrosadenitis. — The hidrosadenitis of Verneuil, or tuberous 
 abscesses of the axilla of Velpeau, are intradermic or subdermic 
 abscesses, the size of an almond to that of a large nut or more, which 
 occur exclusively in the axillary region. 
 
 These abscesses are more common in women, developing espe- 
 cially in cases of intertrigo, lack of cleanliness, hyperidrosis, but 
 principally of axillary eczematides. 
 
 One or more indurations develop, usually without general dis- 
 turbances, with a sensation of pruritus, tension and distress. These 
 indurations are perceptible on palpation, which is painful; gradu- 
 ally they form a demonstrable, hemispherical, red, non-acuminate 
 prominence. 
 
 They may undergo absorption, but more frequently they soften 
 and open through the thinned and reddened skin, emptying a 
 
PYODERM ATI TIDES 545 
 
 creamy pus, but usually no slough. The development of each 
 nodule lasts from ten to fifteen days; they succeed each other, some- 
 times in both axillae, for weeks and months. The affection has a 
 tendency to recur each summer. Complications are rare. 
 
 On account of the differences in appearance and course, as well 
 as the usual non-coincidence of these tuberous abscesses with fu- 
 runcles in other regions, they are believed to be due to a staphy- 
 lococcus infection of the [large axillary] sudoriparous glands rather 
 than of the pilosebaceous follicles. 
 
 The treatment is the same as that of furuncle. The hairs of the 
 region should not be cut or shaved. I have known beer-yeast or 
 various ferments work wonders in cases of protracted duration; the 
 same remark applies to the modern treatment with zinc. Vaccine- 
 therapy is also indicated and sometimes very successful. Scrupulous 
 cleanliness is required to guard against recurrences. 
 
 35 
 
CHAPTER XXVII. 
 INFECTIOUS BACILLARY DERMATOSES. 
 
 The infectious dermatoses caused by bacilli are: cutaneous tuber- 
 culosis; leprosy, glanders, malignant pustule or anthrax, cutaneous 
 diphtheria, soft chancre and probably also the verruga [Peruana] 
 of Carrion and rhinoscleroma. 
 
 A number of other affections have also been attributed to specific 
 or non-specific bacilli, pure or associated, for instance, with spirilla 
 (fuso-spirillary symbiosis), as follows: 
 
 Wound-diphtheria and hospital gangrene, which belong to the 
 domain of surgery; tropical phagedenic ulcer (p. 301, ulcero-mem- 
 branous stomatitis (p. 306), noma (p. 308) and balanoposthitis 
 erosiva circinata (p. 311). 
 
 TUBERCULOSIS. 
 
 The cutaneous manifestations of tuberculosis constitute at the 
 present day an important chapter in dermatology. This chapter 
 has only gradually been built-up and had no scientific basis before 
 the discoveries of Villemin and Koch. 
 
 Thus lupus vulgaris which had been distinguished from the other 
 dermatoses by Willan and Bateman, was named tuberculous only 
 because its characteristic lesion belongs to the class of tubercles, in 
 the dermatological sense of this term. Clinicians — Lugol, Bazin, 
 Hardy, Lallier, Vidal and Besnier- — grouped it among the scrofulides 
 and more or less clearly surmised its tuberculous character. This 
 was demonstrated histologically by Friedlander and others, experi- 
 mentally by Max Schiiller, Leloir and especially by R. Koch. 
 
 The evolution of our views in regard to the other types of cuta- 
 neous tuberculosis has undergone analogous changes. 
 
 Among the features on which a diagnosis of a cutaneous tuber- 
 culosis is based at the present day, only two have a positive scien- 
 tific value, namely : 
 
 1. The presence of Koch's bacillus in the lesions. 
 
 2. The positive outcome of inoculation of the affected tissue into 
 animals, especially guinea-pigs which are sensitive to this infection. 
 
 The other features permit merely a presumptive conclusion, 
 although of considerable weight when several are present. Such 
 features are: 
 
 1. A histological structure in conformity with that of known 
 tuberculous lesions. 
 
TUBERCULOSIS 547 
 
 2. A positive local reaction to Koch's tuberculin A. 
 
 3. A certain clinical appearance and course and special etiological 
 factors. 
 
 4. The coexistence of undoubtedly tuberculous manifestations. 
 A serodiagnosis of tuberculosis unfortunately is not possible. 
 Clinical Forms. — Five pathological types are known which in a 
 
 general way satisfy these conditions and almost regularly present 
 the six features enumerated above : Tuberculous ulcer, tuberculosis 
 verrucosa, tuberculous gumma, fungoid tuberculosis and lupus vulgaris. 
 I grouped these together under the generic heading of "cutaneous 
 tuberculoses." 
 
 The contributions of the last thirty years have shown that there 
 exists in addition a considerable group of dermatoses which without 
 usually fulfilling the first two conditions so frequently comply with 
 the four latter as to justify the surmise of a close connection existing 
 between them and tuberculosis. 
 
 These dermatoses I have named tuberculides and the majority of 
 modern authors interpret them, like myself, as attenuated tuber- 
 culoses. It is only the limitations to be made to this group that is 
 still a subject of discussion. 
 
 It must be emphasized from the start that while this classification 
 and these subdivisions are justified in the great majority of the 
 cases and considerably facilitate their description and study, never- 
 theless numerous transition forms are met with between the various 
 types of cutaneous tuberculoses as well as between these and the 
 tuberculides. The existence of transitions between the various 
 manifestations of the same cause is in no way remarkable. 
 
 General Etiology and Pathogenesis. — It would involve an encroach- 
 ment upon the domain of general pathology to describe in this 
 connection the Koch bacillus, to study its biological properties, 
 its cultures, its secretions, its pathogenic properties in man and in 
 animals, its portals of entry and the modifications apparently 
 wrought in the course of the resulting disease through the properties 
 of the affected territory. It is sufficient to emphasize the great 
 extension of the field of tuberculosis through modern investigations. 
 This infection at the present day appears to be infinitely more widely 
 distributed than was formerly believed. 
 
 It is in reality essentially an infection of childhood. When it 
 attacks the newborn, which is rare, the patients almost invariably 
 die. In the course of late childhood, the number of infected indi- 
 viduals rapidly increases until, according to Naegeli, it reaches the 
 proportion of 96 per cent, shortly after puberty. By no means all 
 of these cases succumb to phthisis, meningitis or tuberculous septi- 
 cemia; the majority resist the infection. When the initial lesions 
 heal, various contingencies may arise : the tuberculosis may become 
 
548 INFECTIOUS BACILLARY DERMATOSES 
 
 entirely latent, only the tuberculin reaction or possibly the autopsy 
 being capable of revealing its existence. Or sometimes, so-called 
 manifestations of local tuberculosis may persist or develop later on 
 (glandular, bony, articular or cutaneous), constituting the " scrofula" 
 of the older writers; furthermore recrudescences or the onset of new 
 manifestations may occur at any time of life. 
 
 The influences which determine the course taken by the tuber- 
 culous infection are multiple and imperfectly known. One may 
 incriminate the nature of the organic soil, the general hygienic 
 conditions, the action of certain infections such as measles, etc., 
 the effect of overwork, repeated pregnancies, etc., but the principal 
 factor in recrudescences and in the development of new lesions 
 undoubtedly is re-infection or superinfection of heterogenous or 
 autogenous origin. 
 
 It has been experimentally demonstrated, however, that the re- 
 infection of an organism invaded by the tubercle bacillus does not 
 produce the same effects as the first inoculation, but different effects; 
 this is known as the allergy of von Pirquet. 
 
 The subcutaneous inoculation of virulent Koch's bacilli into an 
 animal of a very sensitive species, like the guinea-pig, produces at 
 the end of ten or twenty days a nodosity which undergoes ulceration, 
 /'. e., the tuberculous chancre; this is followed by glandular enlarge- 
 ment, then regularly by a generalized visceral tuberculosis affecting 
 chiefly the spleen and the liver, from which the animal dies. Experi- 
 ments on monkeys, in Java, in 1905, under the direction of Xeisser, 
 furnished practically identical results irrespective of the source of 
 the tuberculous virus. 
 
 When an already tuberculized guinea-pig is re-inoculated with 
 bacilli at another point of the skin, preferably between four and six 
 weeks after the first infection, the immediate result is an ecchymosis 
 and a slough which falls off leaving a wound which heals without 
 corresponding glandular enlargement; this is known as Koch's 
 phenomenon ( L891 ) and constitutes a particular instance of allergy. 
 
 In animals of more resistant species, this allergy manifests itself 
 differently and the same is undoubtedly true for man. 
 
 Returning to human cutaneous tuberculosis, with which alone 
 we are here concerned, the following points must not be lost sight 
 of: the individuals in which it is met with are practically all pre- 
 viously infected with tubercle bacilli; the re-infecting agent may 
 he of exogenous or autogenous origin, according as new bacilli come 
 from the outside or from a focus of tuberculosis borne by the patient 
 himself; in the latter case, the cutaneous re-infection may occur 
 through contiguity (derived, for example, from a subjacent bony or 
 glandular tuberculosis), or it may result from a metastasis through 
 the lymphatic route or the blood route. 
 
TUBERCULOSIS 549 
 
 These pathogenic conditions perhaps play a certain part in the 
 diversity of aspect and course of the cutaneous lesions, although a 
 smaller one than that pertaining to the existing state of allergy. 
 
 The question has arisen as to whether the origin and strain of the 
 bacillus may not be concerned in the production of these differences. 
 The bovine bacillus has occasionally been found, in cases of lupus 
 for instance, more often in London and New York than in Paris; 
 but the human bacillus is usually responsible. Burnet has noted 
 some instances of human bacilli of attenuated virulence in cutaneous 
 lesions. Investigations of this question are still under way. 
 
 At any rate, however, it must be admitted that although the 
 reasons are not understood, tuberculosis of the skin manifests itself 
 in lesions of very different form. 
 
 I shall review the principal, most common and most definite of 
 these lesions, noting that they have been arranged on a diminishing 
 scale of clinical malignancy and bacillary content. 
 
 Cutaneous Tuberculosis. — Tuberculous Ulcer. — This name is 
 restricted to a primarily and essentially ulcerative lesion (p. 288) 
 due to the Koch bacillus, which is abundantly present. This affec- 
 tion has also received the names of miliary tuberculosis of the skin 
 and mucous membranes; and acute tuberculous dermatitis. 
 
 Ulcerated lupus, open tuberculous gumma, scrofula and fistulas 
 derived from tuberculous osteitis, etc., do not fall under this defi- 
 nition. 
 
 It was in the mouth and notably on the tongue that tuberculous 
 ulcer was first distinguished from analogous lesions by Ricord and 
 subsequently studied by Julliard, Trelat, Fereol, etc. The observa- 
 tions of Coyne, of Jarisch and Chiari, showed that it occurred also 
 on the integument under an identical form. 
 
 As a rule, tuberculous ulcer is observed only in already badly 
 infected adults, notably in consumptives. 
 
 It has two seats of election: in the mouth, on the lips, tongue, 
 the inner aspect of the cheeks, the pharynx, or in the circumference 
 of the mouth and nostrils; or at the anus and its surroundings. It 
 is rare on the genital organs, but may be found there and give rise 
 to serious difficulties in diagnosis. 
 
 These localizations and the common preliminary of an open tuber- 
 cular lesion of the lung, larynx, or intestines, in the same patient, 
 are suggestive of the fact that tuberculous ulcer is generally refer- 
 able to auto-inoculation of some fissure or erosion with bacilli from 
 the sputum or the feces. 
 
 Sometimes, however, it is the result of contagion. I have observed 
 it on the forehead of an apparently healthy woman, the wife of a 
 consumptive. Cases such as those reported by Lehmann, who saw 
 ten healthy children become infected with tuberculous ulcers of 
 
550 INFECTIOUS BACILLARY DERMATOSES 
 
 the penis by the mouth of a tuberculous rabbi, in the course of ritual 
 circumcision, seem to me to be instances of primary tuberculous 
 chancre, comparable to the chancre of newly inoculated guinea-pigs, 
 but not tuberculous ulcers like those of consumptives. 
 
 At the onset of a tuberculous ulcer, the lesion consists of one or 
 several elevations of a dusky red color, which become lighter and 
 finally evacuate their contents externally. The orifices become 
 confluent and the ulcer extends rapidly on the surface, but slowly 
 in depth. 
 
 I have previously described its typical features in its fully de- 
 veloped stage (page 288), a few of its most common clinical 
 varieties, as well as the grounds on which the diagnosis rests; the 
 reader is also referred to the description of atypical tuberculous 
 ulcers elsewhere in this book (p. 291). 
 
 Treatment. — In a consumptive patient, it suffices to touch the 
 ulcer with camphorated naphthol, lactic acid, peroxide water, 
 methylene-blue, or with a mixture containing iodoform; the pain 
 must be controlled with cocain; if dressings are applicable, iodoform 
 or one of its substitutes, dermatol, airol, europhen, etc., should be 
 employed. 
 
 If the patient does not appear to be tuberculous or only slightly so, 
 the total removal of the lesion is indicated, or in default of this, 
 scraping followed by cauterization with the thermocautery and 
 appropriate dressings. 
 
 Tuberculous Gummas. — These are subcutaneous nodes or nodosi- 
 ties due to the Koch bacillus, which may be demonstrated in variable 
 numbers. Their course tends toward softening and evacuation. 
 They have been described elsewhere (p. 268). 
 
 They are encountered preferably, but not exclusively, in patients 
 in a bad general condition, suffering from visceral tuberculosis or 
 especially from bony or glandular tuberculosis. Children and 
 youthful individuals are more particularly susceptible. 
 
 The treatment of tuberculous gummas varies according to their 
 seat, their number and the general condition of the patient. When 
 they can be extirpated surgically at an early date this is the most 
 advisable procedure. Puncture followed by alterative injections 
 rarely yields good results. When the gumma is open, it may be 
 touched, after scraping if necessary, with iodin solution. Cam- 
 phorated naphthol, iodoform-ether, guai'acol-oil, etc., followed by 
 the application of dry or gomenol-oil dressings. 
 
 Tuberculosis Verrucosa. — The term tuberculosis verrucosa, in ordi- 
 nary use since the very complete investigations of this derma- 
 tological type by Riehl and Paltauff in 1886, has replaced the terms 
 verrucous scrofulide (Hardy, 1800), lupus verrucosus (MacCall 
 Anderson, 1877) and sclerotic papillomatous lupus (Vidal and 
 
TUBERCULOSIS 
 
 551 
 
 Leloir, 1882), which more or less closely corresponded to it. The 
 condition was very thoroughly discussed by H. Moutot, in his 
 These de Lyon, 1907 (Fig. 167). 
 
 Elsewhere in this book I have recorded the clinical description 
 of the lesions and pointed out their usual site (page 247). The 
 patches are sometimes multiple. 
 
 Tuberculosis verrucosa results in the great majority of the cases 
 from an external inoculation. 
 
 It is observed in consumptives as the result of auto-inoculation of 
 their sputum or dejecta; on the other hand, in nurses, butchers and 
 veterinaries, who through their occupation come in contact with 
 tuberculous individuals, human or animal. It may be derived from 
 an auto-infection of the skin by a focus of bony, articular, or 
 tendinous tuberculosis. Tuberculous lymphangitis, which usually 
 
 Fig. 167. — Tuberculosis cutis verrucosa. 
 
 assumes a gummous or fungoid type, sometimes presents a verrucous 
 character. A few scanty Koch's bacilli may be found in the sections; 
 guinea-pig inoculation is usually positive. Some authors believe 
 that tuberculosis verrucosa is due especially to a bovine bacillus; 
 according to others, a human bacillus is more commonly demon- 
 strable. 
 
 The onset, which usually escapes notice, is in the form of a small, 
 hard, horny nodule which frequently suppurates and becomes an 
 abscess. The development of the lesions is centrifugal or serpiginous. 
 
 Lupus tubercles are never demonstrable in the developed stage, 
 but I have noted their appearance in the subsequent cicatrix. 
 
 The duration is very protracted and indefinite. The patch may 
 become partially cicatrized, but a complete spontaneous cure is rare. 
 Tuberculosis verrucosa may lead to lymphatic propagation and 
 visceral generalization; it accordingly constitutes a serious lesion. 
 
552 INFECTIOUS BACILLARY DERMATOSES 
 
 Anatomical Tubercle or verruca necrogenica — described by 
 Laennec, is merely a particular instance of tuberculosis verrucosa. 
 Jt is encountered among medical students, physicians, dissecting- 
 room attendants and nurses; its more rapid course is undoubtedly 
 explained by mixed infect ion. As early as the day following the 
 local infection, through a puncture or contaminated erosion, a 
 painful erythema makes its appearance, followed by the formation 
 of an elevated dermic pustule. In spite of application of various 
 topical agents, the elevation persists, becomes indurated and gradu- 
 ally extends through the confluence of neighboring small pustules. 
 The lesion promptly assumes the appearance of a horny papilloma 
 or a hard tubercle covered by a crust; it is surrounded by a purplish- 
 red halo; it i> painful on pressure. The mixed tuberculous and 
 pyococcic infection may extend deeply, reaching the lymph channels 
 and glands of the elbow and the axilla, causing suppurative adenitis 
 and ultimately a visceral tuberculosis. 
 
 Treatment of Tuberculosis Verrucosa. — This must be early, rapid 
 and energetic. The method of choice is surgical excision, when this 
 is possible. In default of excision, excellent results are obtained by 
 thorough scraping, under local anesthesia, followed by two or three 
 radiotherapeutic sessions during the cicatrization. Z-rays or radium 
 employed alone are not to be recommended. Strong caustic agents, 
 Vienna paste, Unna's white caustic paste, carbonic acid snow or 
 superheated air, may also be employed in certain cases. The cicatrix 
 must always be watched, as relapses are likely to occur. 
 
 Fungoid and Vegetative Tuberculosis. — In addition to tuberculosis 
 verrucosa and lupus tumidus or vegetans, a less common form is 
 observed, which is entitled to the name of fungoid tuberculosis, 
 proposed by Riehl in 1894. 
 
 It presents the appearance, either of a very soft, irregular and 
 [obulated red tumor, or of a flabby, distinctly outlined, mammillated 
 and prominent patch. Its surface may be ulcerated, crusted or 
 partly cicatrized. 
 
 It seems to result sometimes from an exogenous inoculation, in 
 other cases from an auto-infection of the skin derived from a bony, 
 articular or glandular focus. It is met especially on the limbs, but 
 also on the trunk and even on the face. The differential diagnosis 
 from mycosis fungoides, epithelioma, sarcoma, blastomycosis, sporo- 
 trichosis etc., may present serious difficulties, but these can be 
 overcome by the histological examination, bacteriological findings 
 and animal inoculation. 
 
 The following may be considered as varieties of the above form: 
 Tuberculosis frambcesiformis composed of large, soft and extensive 
 papillomatous patches, occupying especially the perigenital regions; 
 it was described by Doutrelepont, Wickham, Hallopeau, Jessner, 
 
TUBERCULOSIS 
 
 553 
 
 etc.; also the tuberculosis fungosa serpiginosa of Jadassohn; further- 
 more, certain tuberculous lymphangitides (fungoid lymphangitic 
 tuberculosis) studied by Bazin, A. Fournier, Morel Lavallee, et al. 
 In the last-named variety, which closely resembles the lymphan- 
 gitic form of sporotrichosis (Fig. 180), a series of lesions are found 
 arranged in succession along the course of lymphatic vessels coming 
 from a tuberculous focus; these lesions may be fungoid or in other 
 cases gummous or verrucous; sometimes a subcutaneous, nodular 
 strand connects the various foci with each other. Hallopeau and 
 Goupil described a lymphangiectasia variety, in which the tuber- 
 culous infiltration is complicated by lymphatic varicosities; it may 
 lead to secondary elephantiasis. 
 
 The treatment of the fungoid tuberculoses must consist in scraping 
 and cauterization. Radiotherapy may render valuable accessory 
 services. 
 
 Fig. 168. — Lupus vulgaris (agminatus, tumidus, non-exedens) with central sclerosis 
 and centrifugal extension. 
 
 Lupus Vulgaris. — Lupus — lupus vulgaris, tuberculosis luposa, 
 Willan's lupus — owes its traditional name to the ulcerative, gnaw- 
 ing, devouring tendency frequently assumed by it. It represents 
 the most common as well as the most polymorphous and most 
 obstinate form of all cutaneous tuberculoses. 
 
 Lupus vulgaris is characterized by its eruptive lesion, the lupus 
 tubercle or lupoma (page 256). 
 
 It is situated, as previously stated, on the face and neck in the 
 great majority of the cases, especially at the nose or on the cheeks; 
 more rarely on the limbs or on the trunk. 
 
 Varieties. — Lupus may assume extremely varied appearances. 
 Such a large number of varieties have been described by authors 
 
554 INFECTIOUS BACILLARY DERMATOSES 
 
 that one is often at a loss as to where to group a given case. Famili- 
 arity with at least the principal forms seems essential. 
 
 Three types of lupus are distinguished according to the distribu- 
 tion of the lupus tubercles: 
 
 Lit pits disseminatus, in which isolated or sometimes very numer- 
 ous ] lipomas are spread over one or more regions of the body; it 
 usually occurs as a sequel of infectious diseases, especially measles; 
 it closely resembles cutaneous sarcoid or lupoid. 
 
 Lupus agminatus is the most common form; the grouped tubercles 
 become confluent in the center of the patch as a disk or plaque and 
 are scattered in the circumference (Fig. 168). 
 
 l/upus diffusus or confluens consists of an often prominent, soft, 
 nodular patch, of a purplish, yellowish or brownish-red color, with 
 rounded, oval or irregular contours; the lupus tubercles are confluent 
 and indistinguishable. 
 
 The degree of prominence of the lupus permits a differentiation 
 between the following forms: 
 
 Lupus Planus. — This comprises numerous varieties, macular, 
 squamous, psoriatiform, erythematoid and colloid, which are suffi- 
 ciently characterized by their designation. Lupus planus is 
 usually of the agminated type. 
 
 Lupus Tumidus or Lupus Elevatus. — This form, which is more 
 common than the preceding, likewise presents varieties: colloid, 
 myxomatous, etc. 
 
 Lupus Hypertrophicus. — An angiomatous variety has been 
 described; a papillomatous variety which practically blends with 
 tuberculosis verrucosa; and an elephantiastic variety which affects 
 the limbs especially. 
 
 The configuration of a lupus patch is of interest only in so far as 
 it is connected with the course of the affection. Discoid, corymbi- 
 form, marginate, circinate, centrifugal, serpiginous, linear, annular 
 and other configurations have been described. 
 
 The developmental tendency of a given lupus is the most impor- 
 tant of all its features. Raver and Devergie already recognized 
 the existence of two great classes from this point of view. 
 
 1. Lupus nou-exedens, which does not ulcerate and manifests 
 itself in type, form and configuration under one of the numerous 
 varieties enumerated above. It grows slowly, continuously or 
 intermittently. 
 
 It not infrequently becomes transformed into a cicatrix at its 
 center; but a recurrent growth of the lupomas in the sclerotic 
 tissue is far from uncommon. When spontaneous total cicatriza- 
 tion occurs, as in lupus planus and even in lupus tumidus, the 
 condition is described as scleroticus or resolutus. 
 
 The erythematoid variety of lupus planus, also known as ery- 
 
TUBERCULOSIS 555 
 
 themato-tuberculous lupus of Vidal and Leloir, was considered by 
 the last-named author as a combination of Willan's lupus with the 
 lupus erythematodes of Cazenave. It gives rise to frequent errors 
 in diagnosis. This is really a superficial tuberculous lupus, as 
 properly recognized by Dubreuilh; the lupomata are small, sub- 
 epidermic, sometimes confluent and not readily perceptible to the 
 unaided eye; but they are distinctly revealed on biopsy. In this 
 variety of lupus, which may invade the nose and the cheeks in the 
 form of a butterfly, there is a pronounced tendency to spontaneous 
 cure; it is of the resolutive type. 
 
 A lupus non-exedens may at any moment of its course become 
 erosive, ulcerative and even mutilating; so that there is no essential 
 difference between this class of lupus and the following: 
 
 2. Lupus exedens, or primarily ulcerative lupus, often takes a 
 violent and rapid course; its exuberant proliferation, its active 
 growth, its relatively rapid extension and the final partial disin- 
 tegration undergone by it, lead to early destruction and mutilation. 
 It assumes one of the following clinical forms : 
 
 Pustular lupus consists of soft elevations the size of a cherry 
 pit, which have a tendency to become confluent and which in less 
 than a month open like abscesses. 
 
 Ulcerative vegetative lupus is composed of soft fungoid infiltra- 
 tions, producing for instance the appearance of a tomato, into which 
 sharp instruments will cut as into butter; the ulceration which 
 results from the breaking-down of the newformation, leads to fear- 
 ful mutilations of the nose, the lips, the velum of the palate, the 
 eyelids, etc. It is described as lupus vorax or lupus phagedenicus 
 when its course is especially rapid. 
 
 Serpiginous tuberculo-ulcerative lupus, which may precede or 
 follow a lupus non-exedens, is seen on the trunk and the limbs even 
 more often than on the face and, like erythematoid lupus, prefer- 
 ably in aged individuals; it consists of a central cicatrix bordered 
 by large pustular crusted, sometimes rupioid, lupus tubercles. It 
 closely resembles the ulcerative-serpiginous syphilides and although 
 its course is slower it may periodically progress very rapidly. 
 
 The varieties of lupus most commonly met with are, briefly: 
 lupus planus agminatus, with a tendency toward central cicatriza- 
 tion; lupus tumidus agminatus in patches, level or protuberant; 
 and tuberculo-crusted or tuberculo-ulcerative lupus serpiginosus . 
 
 It is extremely common for a lupus which has not been treated 
 or even dressed to present itself covered with yellowish or brown- 
 ish crusts; in such cases it is impossible at the first examination 
 and before it has been cleansed to determine the variety to which 
 it belongs. The formation of the crusts and of the erosions con- 
 cealed by them is undoubtedly referable in part to a pyodermic 
 
>56 
 
 INFECTIOUS BACILLARY DER WATOSES 
 
 complication. Lupus which is thus disfigured is ordinarily called 
 impetiginous lupus I Fig. 169). 
 
 All these morphological varieties really possess only a didactic 
 and diagnostic value. Lupus vulgaris is single in character and 
 may very readily assume a variable appearance and behavior at 
 different points or different times. 
 
 Etiology. Topography. Lupus may appear at any age, but in 
 more than one-half of the cases it manifests itself before the fifteenth 
 and rarely after the thirtieth year. It is more common in the 
 female sex and in Northern countries. A certain family predispo- 
 
 Fig 101). — Lupus Lmpetiginosus with multiple foci, showing tin- points of inocula- 
 tion of the skin. The infection probably occurred through the nostrils and the nasal 
 fossa', reaching the nose and the cheek directly; attaining the internal angle of the 
 eye through the lachrymal duct; the submaxillary region by way of the glands; a 
 U-w of the latter were extirpated, as indicated by the keloid cicatrix under the ear; 
 the other glands suppurated and opened on the skin. 
 
 sit ion seems to play a part; A. Ollivier mentions the ease of a family 
 of five children, four of whom had lupus. Very frequently an 
 apparent tuberculosis is found in the ascendants or collaterals; 
 however, as pointed out by Besnier, consumptives do not acquire 
 lupus, whereas lupus patients very frequently develop pulmonary 
 tuberculosis. 
 
 [All forms of lupus and especially the highly destructive forms 
 are rare in America as contracted with their frequency in European 
 countries. The high daily average of sunlight throughout North 
 America may possibly play a role in this relative freedom, hut on 
 
TUBERCULOSIS 557 
 
 the other hand, lupus is common in sunny Italy. It seems more 
 probable in view of the fact that lupus is preeminently a disease of 
 the poor, that the better nourishment of the poorer classes in 
 America is the important factor.] 
 
 Lupus attacks principally, although not exclusively, individuals 
 of a scrofulous habitus, with thick, soft flesh, a pale or florid com- 
 plexion, swollen nose and lips, acro-asphyxia, frost-bite, chronic- 
 glandular enlargements and a readily vulnerable skin; in scrofulous 
 women, the ear-lobes are often cut by the wearing of ear-rings. 
 This classical scrofula is now known to correspond, not to a soil 
 merely susceptible to the bacillus, but rather to an accomplished 
 but attenuated and latent bacillary infection. Lupus accordingly 
 seems to result from a local superinfection of autogenous or exog- 
 enous origin, in an individual in a state of allergy. 
 
 In the tissues of lupus, bacilli are very rare and dozens of sections 
 must be examined before one is found. They have been assumed 
 to be of a special strain or attenuated virulence, which would agree 
 with the slow course of lupus. According to recent findings, the 
 condition is more frequently due to the human than to the bovine 
 bacillus; as to its virulence, the following statements can be made: 
 Inoculation of lupus tissue, correctly grafted into the guinea-pig's 
 peritoneum, gives rise, as a rule, to ordinary tuberculosis, trans- 
 missible to a series of animals; however, in my experience, the 
 inoculation is unsuccessful in over one-third of the cases. Pau- 
 trier, who inoculated neighboring fragments of the same lupus into 
 guinea-pigs, obtained, in the same series, sometimes positive and 
 sometimes negative results. Whatever may be the explanation of 
 these cases, it seems to me that in combination with the clinical 
 data, they justify the interpretation of lupus as a relatively slightly 
 virulent form of cutaneous tuberculosis and even as an intermediate 
 pathological type between the true cutaneous tuberculoses and the 
 tuberculides. 
 
 The portal of entry of the local infection which causes lupus is 
 external or internal. The possibility of its resulting from an 
 accidental inoculation of exogenous origin is attested by authentic 
 cases in which a lupus has been seen to supervene in an apparently 
 healthy person, following upon a wound, perforation of the ear 
 lobules, vaccination, etc. Perhaps the ordinary impetigo of chil- 
 dren may serve as an avenue of entrance. The frequency of lupus 
 on the nose or in its vicinity is accounted for by the infection of 
 the nasal fossae through the dust inhaled in respiration or by contact 
 with the fingers. As a matter of fact, four-fifths of lupus lesions 
 are situated on the face (Fig. 169). 
 
 On the other hand, the origin of the superinfection may be autog- 
 enous and the inoculation of the skin take place from within out- 
 
558 INFECTIOUS BACILLARY DERMATOSES 
 
 ward as in case of lupus following upon broken-down glands, of 
 common occurrence in the neck; or upon tuberculous osteitis, as seen 
 on the limbs. Lupus of the cheek may be due to a tuberculous 
 lymphangitis derived from the nasal fossse. 
 
 Cases in which the bacillus arrives from some internal focus by 
 way of the vascular system are more numerous than is usually 
 assumed. Disseminated lupus lesions are evidently produced by 
 this means, favored especially by a temporary loss of body resist- 
 ance under the influence of measles, grippe, pregnancy, etc. 
 
 On the genital organs, lupus is rare; in women, it has been con- 
 fused with esthiomene. At the circumference of the anus, lupus is 
 often combined with papillomatous tuberculosis or tuberculous ulcer- 
 ations and results from an auto-inoculation with bacilli contained 
 in the dejecta. 
 
 The palmar and plantar regions and, to a certain degree, the 
 trunk but very particularly the scalp, are endowed with a relative 
 immunity toward lupus. 
 
 Lupus of the mucous membranes is encountered in one-third of 
 the cases, but must be looked for. I have pointed out that the 
 initial focus is frequently nasal. Often soft elevations are observed 
 on the anterior portion of the septum leading to perforation of the 
 latter. From here, propagation takes place to the eyelids through 
 the lachrymal passages, but the conjunctiva usually escapes; or 
 to the palate and gums, through the anterior palatine foramen, 
 and more frequently, to the velum of the palate and to the pharynx. 
 
 In the throat, in the mouth and the larynx, lupus usually assumes 
 the appearance of a pinkish mammillated surface interspersed with 
 ulcerations; on the gums, that of a crop of soft red fleshy prolifera- 
 tions; on the tongue it is very rare and almost invariably assumes 
 a papillomatous form, although I have seen a lupus ulcer of the 
 tongue. 
 
 In a general way, although lupus of the mucous membranes 
 belongs to different varieties and although no lupomata of a barley- 
 sugar appearance are here demonstrable, its course and the usual 
 coexistence of lupus of the skin serve to facilitate its diagnosis. 
 
 Course and Complications. — The long duration of lupus and its 
 rebellious character are its most essential features. Lupus per- 
 sisting for ten or twenty years is very common. Feulard reported a 
 case of sixty-eight years' standing. 
 
 Its ulcerative forms, but also up to a certain point those with a 
 tendency to cicatrization, lead to deformities and truly hideous 
 mutilations; ectropion, complete destruction of the nose with 
 stricture or even atresia of the nostrils, buccal atresia, vicious and 
 keloid cicatrices and transformation of the extremities into mis- 
 shapen stumps (Fig. 170) are not uncommon. 
 
TUBERCULOSIS 559 
 
 The course of lupus may be interrupted by congestive, edematous 
 or suppurative exacerbations. 
 
 Recurrent lymphangitis seems to play a part in the elephanti- 
 astic form. Erysipelas , considered as favorable by some authors, 
 appeared rather injurious in the majority of cases. Corresponding 
 glandular enlargement or adenopathy is rather common although 
 not constant. 
 
 Pulmonary and visceral tuberculosis is responsible for a large 
 number of deaths among lupus patients, although it usually takes 
 a slow and protracted course in these cases. Many patients 
 affected with lupus otherwise enjoy excellent health. I have seen 
 several who were married and had a healthy progeny. 
 
 Fig. 170. — Lupus mutilans of the hand. 
 
 Epithelioma is a formidable complication of lupus, on account 
 of its rapidly invasive course. Its frequency has been estimated 
 at 4 per cent, of the cases. The onset of cancer is recognized by the 
 changed appearance of an area of the lupus eruption, where a 
 hard painful proliferation arises and promptly ulcerates or under- 
 goes partial necrosis; biopsy is often required to confirm the diag- 
 nosis. 
 
 Tertiary or congenital syphilis has been charged with creating a 
 predisposition to lupus; a possible association has even been sus- 
 pected on the basis of the sometimes very favorable although 
 incomplete effects of mercurial treatment in some cases of lupus. 
 
 Diagnosis. — The differentiation of lupus from tubercular 
 or tuberculo-ulcerative tertiary syphilides is most frequently 
 demanded. The course and the age of the lesions sometimes 
 
560 INFECTIOUS BACILLARY DERMATOSES 
 
 furnish presumptive evidence; actually, leaving aside lupus exe- 
 dens, it may be stated that lupus requires years to accomplish 
 what syphilis will do in a few weeks or months. The softness, 
 the yellow translucid color of the lupus nodule and its renewed 
 growth in the cicatrix, are characteristic of lupus. However, 
 certain syphilides are "lupoid" to such a degree, even on histo- 
 logical examination, that the question can be settled only by means 
 of the Wassermann reaction and guinea-pig inoculation; the local 
 tuberculin reaction also possesses a real value. 
 
 The color, the opacity, the elastic consistence and the anesthesia 
 of the tubercles of leprosy are sufficiently characteristic to guard 
 against error; all doubts will be removed by a general examination 
 of the patient. 
 
 The confusion of lupus with eczema, impetigo or psoriasis is 
 inexcusable, although it may assume the objective appearance of 
 an impetiginous or psoriatiform eruption. 
 
 The lupoid sycosis of Brocq affects only the hairy regions, is 
 distinctly cicatricial in the center and bordered by suppurating 
 folliculitis. 
 
 The differentiation may prove very difficult between lupus dis- 
 seminata and the sarcoid of Boeck, which I have described under 
 the name of disseminated miliary lupoid; histological examina- 
 tion and guinea-pig inoculation furnish the only reliable criteria. 
 The boundaries between various forms of lupus and tuberculosis 
 verrucosa, or tuberculosis fungoides and its varieties, are indefi- 
 nite, so that well-informed dermatologists will group under one of 
 these headings cases which by others are considered as lupus; 
 at any rate, these dermatoses are of the same nature. 
 
 What I shall have to say further on in regard to lupus erythema- 
 todes, actinomycosis, the blastomycosis, the leishmanioses, etc., 
 will probably suffice to permit the diagnosis of these affections. 
 
 The tuberculin test with Koch's tuberculin A, in subcutaneous 
 injection, when it produces a positive local reaction to a minimum 
 dose possesses real value not only for the recognition of lupus but 
 for the determination of its clinically undemonstrable extent. The 
 cuti-reaction of von Pirquet with crude tuberculin or Morn's 
 procedure which consists in the comparative rubbing of a small 
 lupus surface and a surface of healthy skin with tuberculin incor- 
 porated in lanolin, equal parts, may also be utilized. 
 
 Lupus of the mucous membranes may simulate very different 
 affections; usually the coexistence of lupus of the skin is of great 
 help. In primary cases, the differential diagnosis from focal 
 syphilomata and from papillary epithelioma is extremely difficult; 
 the differential features may be insufficient and biopsy as well as 
 serodiagnosis become indispensable. 
 
TUBERCULOSIS 561 
 
 Treatment. — I shall refrain from entering into details on this 
 inexhaustible topic, restricting myself to practical suggestions. 
 It is evident that the seat, the extent of the lesions, the age, the 
 social condition and the general health of the patient must influ- 
 ence the choice of the therapeutic method. 
 
 When- a lupus is operable without mutilation, the preference 
 must be accorded to surgical removal, with or without autoplas- 
 tics; the tuberculin test should first be carried out in order to 
 recognize its actual limits, following the advice of Neisser and Kling- 
 miiller. Extirpation should accordingly be the method of choice 
 in lupus of the limbs, the trunk, the neck, unless it is too extensive. 
 
 Curettage, if necessary under anesthesia, may yield rapid but 
 unreliable results, only mediocre from the cosmetic point of view; 
 in all cases, this treatment should be combined with cauterization 
 by the actual cautery or caustic agents, carefully watching the 
 cicatrization, during which radiotherapy may usefully be employed. 
 
 Total destruction through cauterization (thermocautery, galvano- 
 cautery, superheated air) or through chemical caustics (such as 
 trichloride of antimony, trichloracetic and hydrochloric acids, etc.) 
 is open to the same objections. 
 
 Abroad, pyrogallol is freely used as a salve (from 5 to 20 per 
 cent.) but it is very painful; the green salve of Unna (see Thera- 
 peutic Notes) seemed preferable to me. 
 
 Most frequently, graduated progressive methods together with 
 physical agents should be resorted to, thereby stimulating or favor- 
 ing the sclerotic process adopted by nature in cases of spontaneous 
 cure. 
 
 Crossed linear scarifications would constitute an excellent cura- 
 tive procedure, in view of the qualities of the resulting cicatrix, but 
 for the often considerable and even endless number of sessions 
 required for this treatment. Nevertheless, scarifications are impera- 
 tive in case of vegetative lupus or lupus vorax, which they control 
 with remarkable rapidity; in lupus of the orifices of the face; and 
 for the correction of lupus cicatrices with a persistent crop of 
 tubercles. 
 
 Ignipuncture with the galvanocautery does not aim at the 
 total destruction of the lupus, but like scarification tends to pro- 
 duce centers of cicatrization which, multiplied by later sessions, 
 lead to confluence. This is a most valuable procedure for the 
 reason that it is inexpensive, more rapid than scarification, easily 
 applicable, particularly adapted to cases of lupus already modified 
 by previous treatment and especially unrivalled in lupus of the 
 mucous membranes. 
 
 As adjuvants of the preceding methods, or even sometimes 
 exclusively, according to some authors, medicinal topical agents 
 
662 INFECTIOUS BACILLARY DERMATOSES 
 
 have been recommended and may prove highly advantageous; I 
 shall quote only potassium permanganate in strong solution or 
 even in substance, pyrogallol, resorcin and especially mercurials in 
 the form of plasters. 
 
 The introduction of new physical methods has partly transformed 
 and certainly improved the traditional therapy of lupus. 
 
 The phototherapy of FinseD undoubtedly yields the best cos- 
 metic results, moreover without pain; on the other hand, it is 
 open to serious objections on account of the considerable number 
 of sessions required (200 to 300 for a lupus of moderate extent), 
 the very high cost of the apparatus and the sessions, as well as 
 the failures, the proportion of which is not inconsiderable. The 
 mercury vapor quartz lamp is more convenient and less expensive. 
 
 Radiotherapy and radiumtherapy have not entirely justified 
 the expectations placed upon them. Their indication and their 
 mode of employment in lupus are still a matter of controversy. 
 However, the majority of authors are agreed in the repudiation 
 of destructive doses which involve the risk of sometimes tardy but 
 always formidable radiodermatitis. Injudicious repetition of the 
 sessions involves the same dangers. In moderate doses, the radia- 
 tions are very efficient in fungoid or papillomatous lupus and in 
 superficially ulcerated lupus lesions. But the x-rays are especi- 
 ally to be recommended as adjuvants and I may say that at the 
 present writing, galvanopuncture or periodical scarifications fol- 
 lowed by radiotherapy in cautious dosage, seem to constitute the 
 best treatment of lupus not amenable to surgical extirpation. 
 Radium should be accorded the preference in cases of lupus of the 
 mucous membranes or lesions difficult of access. 
 
 Internal treatment alone must never be relied on for the cure of a 
 lupus, but there is often reason for and marked benefit to be expected 
 from medication with calcium, arsenic, cod-liver oil and iodides; as 
 well as from a sojourn in suitable watering-places by the seaside 
 or on high mountains. This climatotherapy may be combined with 
 heliotherapy, which is very beneficial when properly employed. 
 
 Among the various hypodermic injections which have been 
 advocated, notably cacodylates, cantheridin, nuclein, thiosinamin, 
 etc., in my opinion calomel injections are the only ones which can 
 sometimes be recommended. When applied as in the treatment 
 of syphilis, they are capable of producing remarkable improve- 
 ment, but are found to be very unreliable; on the other hand, 
 systematic injections, in gradually increased doses, of Koch's tuber- 
 culin A, which I have resumed after many other trials, have some- 
 times yielded remarkably rapid favorable results in my experience; 
 great caution is required in their use. 
 
 The treatment of lupus needs insight, considerable patience and 
 
TUBERCULOSIS 563 
 
 skill in the variation and combination of the methods best adapted 
 to the individual case as well as indefatigable perseverance in the 
 management of partial relapses. A cure cannot be considered as 
 practically certain until several years have elapsed after the dis- 
 appearance of the visible lesions. 
 
 Tuberculides. — Since my suggestion in 1896 a number of appar- 
 ently very dissimilar dermatoses have been grouped under this 
 heading, whose relations with tuberculosis are proved by the follow- 
 ing features. 
 
 The tuberculides themselves are frequently associated in the 
 same individual and very often coexistent with glandular, bony, 
 serous, visceral or cutaneous tuberculous manifestations; or the 
 patients have a tuberculous history, or are found to be tuberculous 
 later on. 
 
 The histological structure of the tuberculides is sometimes 
 typically tubercular and identical with that of the most positive 
 tuberculoses; in other cases it is non-tubercular, inflammatory and 
 necrotic; but this is now known to be the case even in certain 
 undoubtedly bacillary tuberculoses. 
 
 As a rule, no Koch's bacilli are found in the tuberculides; how- 
 ever, several authors report their discovery by means of the 
 improved methods of Much-Gram, with antiformin, etc. Inocu- 
 lation of their tissue into guinea-pigs is usually negative; but 
 exceptions to this rule have occurred, diminishing the demon- 
 strative value of the usual negative findings. Furthermore, it is 
 noteworthy that Gougerot experimentally produced analogous 
 lesions, which he regards as identical with tuberculides, by rubbing 
 pure cultures of Koch's bacilli on the shaved skin of the guinea- 
 
 Pig- 
 
 The tuberculin test is often, but not invariably, positive in the 
 tuberculides. 
 
 From the point of view of their clinical course, the tuberculides 
 in general are distinguished from the cutaneous tuberculoses by 
 their usual occurrence in a disseminated form, which is less com- 
 mon in the latter; and moreover by their marked tendency to 
 spontaneous cure. 
 
 They appear in successive crops, without fever, without dis- 
 turbance of the general condition; they often have a symmetrical 
 distribution and a variable but rather prolonged duration. The 
 various forms have a marked predilection for certain periods of life 
 and for certain regions which are predominantly affected. 
 
 Clinical Forms. — As nearly all the forms of tuberculides were 
 observed and described before their real nature was suspected, 
 the names they bear are based on their morphological appearance, 
 so that their nomenclature is a regular Joseph's coat. To bring 
 
564 INFECTIOUS BACILLARY DERMATOSES 
 
 some order into this disorder, I recommend the following classifi- 
 cation : 
 
 A. Cutaneous Tuberculides. — The seat of the lesions is dermo- 
 epidermic in the following forms: 
 
 1. Lichenoid tulwrculides (lichen scrofulosorum and lichen nitidus 
 — these forms have already been sufficiently described (pp. 146, 
 138). I have seen also a few rare cases which simulated patches 
 of lichen planus. 
 
 '2. Papulonecrotic tuberculides (folliclis and acnitis of Barthelemy). 
 
 3. Acneiform tuberculides (acne cachecticorum of Hebra) — this is 
 simply a variety of the preceding form. 
 
 4. Lupoid tuberculides (benign sarcoids or lupoids of Boeck 
 (p. 259). 
 
 5. Erythemato-atrophic tuberculides (lupus erythematodes of Caze- 
 nave and certain atrophodermas). 
 
 6. Erythematous tuberculides (lupus erythematodes exanthema- 
 ticus). 
 
 B. Hypodermic Tuberculides. — Three principal types have been 
 described: the erythema induratum of Bazin, the subcutaneous 
 sarcoids of Parier-Roussy and the disseminated nodular sarcoids; 
 in all probability these are simply varieties of the same species 
 (p. 272). Certain scrofulous gummas of attenuated virulence 
 (p. 268) and a few atypical tuberculous ulcers (p. 291) are 
 evidently related to this group. 
 
 C. Doubtful Tuberculides. — It is necessary to point out in this 
 connection a certain number of affections whose relations with 
 tuberculosis are emphasized by some authors but denied by others; 
 these relations are problematical or perhaps indirect. Such con- 
 ditions are: 
 
 Certain forms of frost-bite (pernio tuberculides) (p. 34). 
 Piti/riasis rubra of Hebra-Jadassohn (erythrodermic tuberculide) 
 
 <P- li8) / 
 Certain forms of parapsoriasis (parapsoriatic tuberculides?) 
 
 (p. 111). 
 
 Pityriasis rubra pilaris (erythrodermic perifollicular tuberculide?) 
 (p. 399). 
 
 Perhaps certain cases of eczema folliculorum of Malcolm Morris 
 and a few other authors (eczematoid tuberculides?) (p. 396). 
 
 Perhaps also angiokeratoma (angiokeratotic tuberculides) (p. 
 695). 
 
 This enumeration, lengthy as it is, does not exhaust the subject. 
 As a matter of fact, only the relatively common and fairly well- 
 established clinical types have so far been described under a special 
 name. There exist more rare types as well as some with mixed 
 features and transition forms as yet unclassifiable. I have seen 
 
TUBERCULOSIS 565 
 
 cases, for example, which might have been indifferently diagnosed 
 as lupus pernio or folliclis or lupus erythematodes; all that could 
 be stated was that the case was one of tuberculide. One would 
 naturally hesitate to lay down exact rules for unique cases or for 
 transition forms which are of exceptional occurrence. 
 
 Nature and Pathogenesis. — According to their mental proclivities, 
 authors have conceived a different and even contradictory inter- 
 pretation of the nature of these dermatoses. In the opinion of 
 some, their relations with tuberculosis were extremely doubtful. 
 Tuberculosis, they said, is a disease so widely distributed that its 
 presence in a patient or his environment is irrelevant. The course 
 of the tuberculides, the absence of really scientific proofs of their 
 bacillary origin, justify neither their arbitrary grouping with the 
 legitimate tuberculoses nor the assumption of their kinship with 
 them. 
 
 Others, on the contrary, regarded the tuberculous nature of these 
 affections as so unquestionable that it was actually proposed to 
 abandon the provisional term of tuberculides and to incorporate 
 this group among the cutaneous tuberculoses, of which they were sup- 
 posed to represent still more attenuated types than lupus vulgaris, 
 for example. The dissemination and customary symmetry of tuber- 
 culide eruptions were explained as due to the virus having travelled 
 by the vascular route. With reference to the attenuated virulence 
 of the lesions, various interpretations were suggested. The theory 
 of Hallopeau, according to which the tuberculides are dependent, 
 not on the bacilli themselves, but on their soluble toxins (toxi- 
 tuberculides) met with many objections. The interpretation of 
 Haury appeared much more probable; in his opinion the tubercu- 
 lides result from embolisms of dead or attenuated bacilli, perhaps 
 due to the struggle they had undergone against the defensive forces 
 of the organism in a primary glandular or other infectious focus 
 or in the blood current. These bacilli arrive in the skin while still 
 capable of exciting a temporary local reaction and even small 
 necrotic foci; but they succumb or disappear more or less rapidly — 
 hence the spontaneous cure and non-inoculability of the lesions. 
 
 By applying to the interpretation of the tuberculides the preva- 
 lent view of tuberculous infection, their pathogenesis becomes con- 
 siderably clearer. Tuberculosis is an almost universal infection; 
 it heals very often to the point of becoming clinically latent; but it 
 remains nevertheless capable of reviving under various influences 
 and of giving rise to a discharge of bacilli; it creates a state of 
 relative immunity which manifests itself by the phenomena of 
 allergy. It thus becomes intelligible that the cutaneous manifes- 
 tations resulting from bacillary embolisms may vary greatly in 
 form and behavior, according to the degree of attenuation of the 
 
566 tNFECTIOUS BACILLARY DERMATOSES 
 
 bacilli, according to the Dumber of imported bacilli, as well as 
 according to the degree and kind of allergy enjoyed by the indi- 
 vidual. But these incomplete data and speculations still require 
 definite scientific confirmation. 
 
 Papulonecrotic Tuberculides. This clinical form was first described 
 under the name of lupus erythewaforfe* rfisxcniiiKitiix (Boeck, 1880), 
 then as cicatricial folliculitis of the hairless part* (Brocq), as fob- 
 liclis and aortitis (Barthelemy) [as hydradenitis destruens suppurativa 
 (Pollitzer)], as hidrosadenitis suppurativa disseminata (Dubreuilh); 
 Kaposi called it acne telangiectodes. 
 
 It is not very rare and occur- especially in adolescents and young 
 adults. 
 
 The eruption, consisting of a very variable number of lesions, 
 appears in successive crops. It occupies preferably the hands and 
 the fingers, the forearms (Fig. 171), the elbows, the circumference 
 of the knees, the feet, the face, the ears and not infrequently also 
 the trunk. 
 
 Fig. 171. — Papulonecrotic tuberculides. In this patienl the eruption occurred on 
 t lie* four extremities. 
 
 The typical lesions begin as a very minute dull-red elevation, 
 which on palpation reveals a hard painless nodule, the size of a 
 pin-head, more or le>s deeply imbedded in the cutis; in about a 
 week, this nodnle becomes raised, its surface turns livid and pur- 
 plish, while an epidermic vesico-pnstule appears at its summit. 
 When this is opened with a pin, only a very small amount of turbid 
 serum escapes, and a sharp-bordered depression with a grayish 
 floor appears in the cutis. Left unopened, the lesions become 
 transformed into crusts which are not shed till after two to four 
 weeks and leave distinct depressed cicatrices, often pigmented in 
 their circumference and fairly characteristic. The crops following 
 one another, the different stages are observed simultaneously. The 
 total duration is several months or several years, with a tendency 
 to seasonal recurrences. 
 
TUBERCULOSIS 
 
 567 
 
 With this principal type, which may be designated as folliclis, 
 the following varieties are connected. 
 
 Acnitis of Barthelemy (Fig. 172) is seen in youthful or adult 
 individuals, beginning and always predominating on the face, 
 although sometimes scattered over the extensor surface of the 
 limbs and the genital organs. The lesions consist of hard, miliary, 
 distinctly circumscribed, isolated and indolent nodules, which 
 originate in the depth of the cutis, may become absorbed, but more 
 frequently suppurate and open on the surface, leaving a minute 
 cicatrix behind. Each lesion lasts about one month, the eruption 
 is continued over several months and is subject to recurrence. 
 
 Fig. 172. — Acnitis in a man aged twenty years. 
 
 Acne cachecticorum consists of slightly raised papulo-vesicular or 
 superficial pustular miliary lesions, with a livid base, which appear 
 in crops, without pruritus, in children or sometimes in adolescents 
 or adults; they are situated principally on the limbs, to a small 
 extent on the trunk and on the face and scalp. As a rule they 
 are intermingled with lichen scrofulosorum or with typical papulo- 
 necrotic tuberculides, of which they represent a superficial variety. 
 
568 INFECTIOUS BACILLARY DERMATOSES 
 
 The name of ecthyma terebrans scrofidosorum may be applied to 
 tuberculides related to the papulo-necrotic variety, but char- 
 acterized by an eruption of lenticular or especially nummular, 
 shallow and painless ulcerations which may coalesce in irregular 
 patches; their course is slow, although occasionally acute. 
 
 With the exception of the acnitis type, which usually seems to 
 be pure, the other varieties have a tendency to become combined 
 with each other. They also become associated with small deep 
 nodosities, analogous to scrofulous gummas of very small size. 
 
 Not to mention the coexistence of a local, glandular, etc., tuber- 
 culosis, which is common, the combination of papulo-necrotic 
 tuberculides with aero-asphyxia, with pernio, with lichen scrofulo- 
 sorum, with lupus erythematodes, etc., is far from unusual. 
 
 As their objective appearance is on the whole very polymorphous, 
 when the various cases are taken into consideration, the differential 
 diagnosis may have to be made from acne vulgaris, whose lesions, 
 topography and course are entirely different; from some forms of 
 folliculitis decalvans; and especially from papulo-crusted or follicular 
 syphilides. Careful examination, however, will show that one is 
 not dealing with the folliculoses, for the palmar and plantar regions 
 may be involved ; lesions have been met with on the buccal mucosa. 
 Hidrosadenitis must likewise be excluded. In other cases the 
 differentiation is not easy from frost-bite, or lupus erythematodes 
 with small patches, or still other tuberculides. 
 
 The pathological anatomy will be discussed later. 
 
 The treatment must aim in the first place at correcting the 
 general hygiene and nutrition. So-called anti-scrofulous medica- 
 tion with iodides, cod-liver oil and arsenic, is classical in these 
 cases; calcium-salts remedies are indicated. I have obtained 
 remarkable results from injections of calomel or soluble salts of 
 mercury in cases with a negative YVassermann reaction. Still 
 more serviceable are intravenous injections of arsenobenzol, com- 
 bined with tuberculin injections in minimal and repeated doses. 
 Locally, applications of ichthyol, methylene-blue, tincture of iodin 
 or iodide powders, according as the lesions are ulcerated or not, 
 seem to be useful. In obstinate cases, recourse may be had to 
 cliinatotherapy, to heliotherapy and to cures at watering-places 
 with saline, arsenic or sulphur springs. 
 
 Lupus Erythematodes. — Although clinically and histologically 
 very different from lupus vulgaris or Willan's lupus, erythematous 
 or Cazenave's lupus is likewise destructive and disfiguring; hence 
 its name. There is not so much difference in its true nature; if 
 lupus erythematodes is an erythemato-atrophic tuberculide, as 
 there is good reason to believe. 
 
TUBERCULOSIS 569 
 
 Symptoms. — Lupus erythematodes consists of distinctly cir- 
 cumscribed red patches, covered with adherent scales; they are 
 only slightly infiltrated and have a tendency to become atrophied 
 at their center; their course is slow; they occupy with predilection 
 the face, the ears, the scalp, the back of the hands and the fingers. 
 
 Each of these features deserves separate study. 
 
 The redness is constant, sometimes of a light pink or again of 
 a carmine or livid shade. It results from a persistent erythematous 
 inflammation and fades under vitropressure. Very frequently, 
 however, the congestion is accompanied by the existence of a fine, 
 reticular or stellate network of telangiectatic capillaries and some- 
 times by punctiform hemorrhages. 
 
 The scaling is very characteristic but varies greatly in degree. 
 In typical cases, a very adherent, more or less continuous, hyper- 
 keratosis is demonstrable, formed by fine, greasy, dirty-white or 
 chalky lamellae or stratified layers, which often look as if imbedded 
 in a depression of the epidermis; rarely, the desquamation is psoriat- 
 iform. When this hyperkeratosis is slightly marked, it consists 
 simply of a whitish stippling around the follicular orifices. The 
 thick lamellar or chalky layers present small horny processes on 
 their deep aspect, which penetrate into the follicles and correspond- 
 ing depressions of the epidermis. This punctate cornification is 
 one of the characteristic symptoms of lupus erythematodes. 
 
 The infiltration is very slightly marked and usually consists of 
 a slight turgescence of the borders of the spot, the center being, 
 on the contrary, depressed. Cardboard induration or discoid 
 elevation of the patches is exceptional. 
 
 On the other hand, cicatricial atrophy is invariable and char- 
 acteristic, although very variable in degree and depth. Unna, on 
 this account, gave lupus erythematodes the name of ulerythema 
 centrifugum (dvkr) = cicatrix). The cicatricial atrophy (p. 339) 
 results from absorption, without ulceration, of part of the cutis and 
 of the infiltration. When mild and superficial, it manifests itself 
 as a delicate white sclerotic network, with grayish punctiform 
 meshes, or as a thin and flexible, not very noticeable patch; it is 
 usually depressed, pearly white and slightly indurated; the deep 
 forms of lupus erythematodes leave a white sclerotic spot, without 
 hairs and glands, sometimes squamous or pigmented. 
 
 The tenderness of lupus erythematodes spots on contact, pres- 
 sure and especially scratching, is a sufficiently constant symptom 
 to merit attention. 
 
 The outlines of the spots are sharp, rounded, oval or polycyclic; 
 they are always bordered by a narrow erythematous margin, even 
 when the central redness is concealed by the hyperkeratosis. 
 
 According to the relative importance of the dermic and the 
 
570 
 
 INFECTIOUS BACILLARY DERMATOSES 
 
 epidermic lesions, i 
 appearances which 
 employed 
 
 ade between different clinical 
 pecial names still sometimes 
 herpes cretaceus of Devergie, 
 
 distinction is n 
 
 have received 
 A case is described as 
 when a massive surface hyperkeratosis is present; as acneiform 
 lupus, when the hyperkeratosis is especially marked at the pilo- 
 sebaceous orifices; as seborrhea congestiva (Hebra); or as erythemato- 
 follicular lupus (E. Besnier), when there are oily crusts provided 
 with very apparent conical processes, penetrating into the follic- 
 ular orifices; as erythema eentrifugum of Biett, when congestion 
 
 fine desquamation predominates. In lupus 
 
 associated with 
 
 exanthematicus the lesions are still less marked. 
 
 It is noteworthy that in the majority of the cases the characters 
 are not pronounced, or they are mixed so that their development is 
 relied upon fully as much as their morphology for the description of 
 the following varieties: 
 
 Fig. 173.— F 
 
 A. Lupus erythematodes discoides, or the fixed form, begins as 
 one or several congestive, slightly infiltrated spots, promptly 
 covered with adherent scales, spreading very slowly like a grease 
 spot; their duration is counted by years. The hyperkeratosis and 
 infiltration are usually very marked. The subsequent cicatrix is 
 very atrophic; on the nose and ears it adheres to the cartilages 
 which are themselves atrophic, hence rigidity, thinning and notable 
 deformity of these parts. Recrudescence of the lesions in the 
 cicatrix is not uncommon. This form is extremely obstinate. 
 
 Discoid or fixed lupus erythematodes (Fig. 173) preferably 
 occupies the cheeks, the ridge of the nose, the temples, the ears, 
 the forehead, the scalp, the neck and more rarely the back of the 
 hands. Not infrequently it is arranged as a continuous patch 
 symmetrically covering the nose and both cheeks, known as butter- 
 
TUBERCULOSIS 571 
 
 fly'or bat-wing lupus (vespertiUo). The spots, however, may also 
 be irregularly scattered, sometimes there is only a single spot. 
 
 Localization on the buccal mucosa is generally considered as 
 rare, although Th. Smith (1906) found it in 16 out of 56 cases. 
 Most commonly it occupies the posterior aspect of the lower lip, 
 where the extension of a red festooned or frayed surface from a 
 lupus patch beginning on the free border of the lip may be observed. 
 Cases of lupus erythematodes of the mucous surface of the cheeks 
 or palate are not very numerous; lesions have been observed even 
 on the tongue, in the form of a red or purplish spot with a parch- 
 ment-like center and radiating leukoplasic margins, resembling 
 buccal lichen planus. The diagnosis can be confirmed only on the 
 basis of a coincident lupus erythematodes of the face, or through 
 biopsy. 
 
 B. Lupus Erythematodes Migrans or Erythema Centrifugum of 
 Biett. — Cases taking a relatively rapid course are connected by 
 imperceptible transitions with stationary lupus erythematodes and 
 their association is not uncommon. 
 
 A tendency to symmetry, to bat-wing form, to involvement of 
 the ears and the hands, is much more marked in lupus migrans. 
 The mucous membranes were never found to be involved. 
 
 The initial rose-colored spots grow in a few weeks, often present- 
 ing raised borders due to a soft infiltration and a central depres- 
 sion; they may become confluent in extensive surfaces. 
 
 Desquamation is moderate and may be compared to that of 
 pityriasis or psoriasis or seborrhea. 
 
 The affection undergoes exacerbations, interrupted by long 
 stationary stages. After healing, the cicatrix may be but slightly 
 noticeable. The differential diagnosis from rosacea is sometimes 
 difficult. 
 
 C. Lupus Pernio. — There is no agreement as to the identity of 
 lupus pernio, lupus frost-bites or chilblain lupus of Hutchinson 
 and its relations with lupus vulgaris on the one hand and with 
 lupus erythematodes on the other. Lupus pernio presents itself 
 in the form of a bluish-red edematous swelling with diffuse borders, 
 occupying the nose, the malar regions, the ears, the back of the 
 hands and the fingers and more rarely the toes; it develops under 
 the same conditions as frost-bite and is not infrequently com- 
 bined with acro-asphyxia, with papulo-necrotic tuberculides, with 
 angiokeratoma, etc. Sometimes there is considerable analogy 
 with Raynaud's disease. The lesions may become atrophied or 
 ulcerated, giving rise to disfiguring scars. The affection lasts 
 many years, with prolonged remissions which occur especially in 
 the warm season. 
 
 When vitropressure or histological examination after biopsy 
 
572 INFECTIOUS BACILLARY DERMATOSES 
 
 shows yellowish nodules analogous to lupus nodules in the spots or 
 patches as is seen particularly on the nose, the condition would 
 seem to be a true lupus pernio, representing a pathological type 
 related to the sarcoids, for which the name of "benign lympho- 
 granuloma" has been proposed (J. Schaumann). 
 
 Swollen erythematous patches, with an atrophic central depres- 
 sion, situated especially on the hands and fingers, may be said to 
 be characteristic of chilblain lupus, which is probably related to 
 lupus erythematodes. Both forms are entitled to classification 
 under the heading of tuberculides. 
 
 D. Lupus Erythematodes K.ranthematicus. — Under this name are 
 described various rather rare erythematous tuberculides, character- 
 ized by lilac-red, finely scaly centrifugal spots becoming super- 
 ficially confluent. They may spread in two or three weeks from 
 the face and hands to the neck, the trunk and the limbs. 
 
 The acute form, described by Kaposi in 1S72, has been observed 
 either in young women already suffering from stationary lupus ery- 
 thematodes of the face; or primarily. The primary variety was 
 investigated in 1908 by G. Pernet, who collected 10 cases, 9 of 
 which occurred in women. The course is rapid, febrile, with 
 arthralgias, albuminuria and severe general disturbances; it almost 
 invariably leads to death in a few weeks or months, through toxemia 
 or through lesions of the respiratory apparatus, the kidneys or 
 the meninges. 
 
 In the subacute form, the spots are disseminated and the general 
 phenomena are absent, lengthy remissions occur and retrogression 
 is possible. 
 
 The dermatosis designated as erysipelas perstans faciei by Kaposi, 
 or as erythema perstans by Jadassohn, in which the red and edema- 
 tous patches appear in a given region, preferably in the center of 
 the face, possibly belongs to the same type. 
 
 Lupus erythematodes exanthematicus usually has no evident 
 tendency toward atrophy. 
 
 Diagnosis. — Lupus erythematodes is distinguished: from rosacea, 
 by the limitation of the red spots and by their scaly atrophic 
 character; from psoriasis and psoriatiform eezematides, by its 
 punctate adherent hyperkeratosis and by its tendency to atrophy; 
 from senile keratosis, by the age of the patients, by its more pro- 
 nounced redness and its non-verrucous surface. 
 
 The cicatrices of lupus erythematodes of the scalp differ from 
 those of pseudofavus, favus and scleroderma in that they have 
 followed upon a stage of severe reddening with hyperkeratosis. 
 On the face or on the body, they must be distinguished from the 
 idiopathic macular atrophies (p. 344) ; this is sometimes extremely 
 difficult (Thibierge). 
 
TUBERCULOSIS 573 
 
 I repeat that the differential diagnosis from papulo-necrotic tuber- 
 culides, frost-bite and other tuberculides may be very puzzling, but 
 is of minor importance. 
 
 Lupus erythematoides (p. 554) is characterized by lupomas which 
 are sometimes difficult to make out without the aid of biopsy. 
 
 Etiology and Character. — Lupus erythematodes is observed very 
 rarely in children before the eighteenth year or in aged individuals 
 after sixty years; it is common from twenty-five to forty-five years, 
 especially in the female sex and in cold climates. [In American 
 dermatological practice it occurs once in about three hundred cases 
 of skin diseases.] General circulatory disturbances, acro-asphyxia, 
 a tendency to facial erythrosis and consequently the gastro-intestinal 
 and utero-ovarian disturbances which are often primarily responsible 
 for these conditions are thought to be predisposing factors. 
 
 The most interesting question, however, concerns the relations 
 of lupus erythematodes with tuberculosis. It results from an 
 international inquiry conducted by the Annates de Dermatologie 
 (April, 1907), that only a little less than one-half the authors 
 accept its tuberculous origin, which has been conceded in France 
 since 1881. It has not been demonstrated, but the opposite 
 theories, which claim a toxinic, nervous or microbic pathogenesis, 
 are still less firmly grounded. Lupus erythematodes is interpreted 
 by Brocq as a cutaneous reaction, which may result from a variety 
 of causes, the most common cause being tuberculous infection.. 
 [This very nearly represents the opinion of Jadassohn also.] The 
 following facts must be kept in mind: Many patients suffering 
 from lupus erythematodes are tuberculous or very probably so; 
 a few, however, seem actually free from tuberculosis. I have 
 repeatedly seen patches of lupus erythematodes developing in 
 connection with "scrofulous" lesions. The general tuberculin 
 reaction is inconstant in these patients; the local reaction is absent 
 in practically all of the cases. The histological lesions are inflam- 
 matory and not tubercular [in the anatomical sense] ; giant cells are 
 rare, no bacilli are found; these features are shared by several types 
 of tuberculides. 
 
 However, although it must be admitted that the number of 
 cases is very small, Gougerot as well as Br. Bloch and Fuchs suc- 
 ceeded in rendering guinea-pigs tuberculous through inoculation 
 with tissue from lupus erythematodes. 
 
 Summarizing, it may be stated that lupus erythematodes is 
 certainly not a cutaneous tuberculosis like lupus vulgaris; never- 
 theless, on account of its pathological relations, it may be grouped, 
 although with some reservations, among the tuberculides. 
 
 Treatment. — Without being positively grave, lupus erythematodes 
 is disfiguring and very obstinate; it is rare for patients suffering 
 from the disease to reach an advanced age. 
 
574 INFECTIOUS BACILLARY DERMATOSES 
 
 The local treatment must be governed by the clinical form. 
 One must avoid attacking with caustic agents superficial spots 
 which max - disappear practically without a trace. In a general 
 way, it is advisable to begin always by cautiously testing the 
 patient's capacity of reaction, by means of astringent lotions, like 
 lead water, or by applying weak ichthyol or resorcin pastes alter- 
 nating with bland powders. 
 
 Gradually more energetic methods are employed and these must 
 be varied in the course of the treatment. Painting with iodin, 
 carbolic acid, arsenic; pyrogallol, resorcin, salicylic acid, oil of cade 
 or mercurial plasters, etc., are usually valuable. 
 
 One of the best alterative agents is potash soap, which is applied 
 during a time progressively lengthened from half an hour to eight 
 or ten hours, to the point of producing an inflammatory reaction, 
 which must then be controlled and the soap-treatment several times 
 repeated. 
 
 In the superficial and actively extensive forms, high-frequency 
 currents sometimes yield remarkable and rapid results. 
 
 In the stationary form, crossed linear scarifications or interstitial 
 ignipuncture with the galvanocautery, more or less deep according 
 to the case, constitute a classical treatment, the only objections 
 to them being that they are rather painful and somewhat slow in 
 action. 
 
 Phototherapy is rarely successful; radiotherapy or radium are 
 preferable, but difficult to apply, requiring extreme care in this 
 particular instance. [I have seen excellent results follow the use of 
 the Kromayer lamp applied with pressure.] 
 
 On the whole, the therapy of lupus erythematodes is extremely 
 disappointing. Patience and diplomacy are called for. It is 
 important not to neglect hygienic measures and general treatment 
 which is identical with that of an attenuated tuberculous infection. 
 Long-continued administration of arsenic and especially of quinin 
 in large doses, combined with iodin externally has been justly 
 recommended. 
 
 Pathological Anatomy of the Cutaneous Tuberculoses and Tuber- 
 culides. This group of diseases comprises an entire series of lesions, 
 from the most obvious bacillary tubercles to atypical and relatively 
 common reactions. 
 
 Tuberculosis. —There exists no tuberculous affection where better 
 tubercles are found than in tuberculous ulcer (Fig. 101). It seems 
 unnecessary to describe them here. They are arranged or scattered 
 ncai' the floor and the borders of the loss of substance, but are often 
 only slightly evident near the surface of the nicer itself. Koch's 
 bacilli are abundantly present. Furthermore, there is a demon- 
 strable inflammation of the connective and muscular tissues, as 
 
TUBERCULOSIS 575 
 
 well as vascular lesions; their degree and their extent are variable, 
 in different cases. 
 
 The yellow granules of Trelat are due sometimes to intrapapillary 
 or subpapillary agminated tubercles, undergoing a caseous degener- 
 ation; in other cases to small superficial abscesses due to secondary 
 infections. 
 
 A tuberculous gumma in its formative stage consists of a mass 
 of tubercles with typical nodules, in course of caseation. Bacilli 
 are rarely present in considerable number. Sometimes the new- 
 formation is encysted in a fibrous sheath, perhaps resulting from the 
 dilatation of a lymph- vessel cavity; more frequently its boundaries 
 are diffuse. In the stage of evacuation of the gumma, the tubercles 
 are hidden in an abundant inflammatory tissue where they are not 
 so readily demonstrable. 
 
 In tuberculosis verrucosa, lupus scleroticus and anatomical 
 tubercle, there are well-marked hyperkeratosis and hypergranulosis, 
 hypertrophied interpapillary proliferations, elongated but very 
 irregular and uneven papillae. The appearance at first sight is that 
 of an ordinary papilloma, sometimes of a verrucous nevus. But the 
 papillary body and the cutis are infiltrated with abundant round 
 cells, sometimes collected in miliary abscesses. Moreover, scanty but 
 very typical tubercles separated by sclerotic tissue may be seen here 
 and there in the deeper portions of the cutis. Bacilli are present in 
 variable number ; the result of guinea-pig inoculation is always p ositi ve . 
 
 In fungoid tuberculosis, the tubercles and the bacilli are very 
 thinly scattered in ordinary infiltration tissue. 
 
 The pathological anatomy of lupus vulgaris is somewhat different 
 in different cases. The most characteristic appearance has been 
 described elsewhere in this book (Fig. 89). The collections of 
 tubercles may be rich in giant cells or without these and composed 
 solely of epithelioid cells ; sometimes the latter are absent and nothing 
 is demonstrable but a diffuse infiltration of lymphoid and plasma 
 cells, interspersed with enormous giant cells; the last-named struc- 
 ture belongs especially to ulcerative and exuberant lupus. 
 
 The lupus tissue in all cases is distinctly circumscribed; the con- 
 nective tissue and elastic fibers stop at its circumference; this 
 fact explains the softness, the translucidity and the very evident 
 clinical boundary of lupomata. 
 
 The lupus infiltration is situated at a very variable depth accord- 
 ing to the clinical form; under the epidermis, in the corium, or as 
 far as the hypoderm. In the last named layer or perhaps at a certain 
 distance from the apparent nodule, it is not uncommon to meet with 
 tuberculous infiltrations following the lymphatic or venous routes, 
 or with aberrant islands, accounting for the very frequent recrudes- 
 cences after a destruction supposed to be complete. 
 
576 INFECTIOUS BACILLARY DERMATOSES 
 
 The connective tissue of the vicinity is often edematous and 
 interspersed with lymphoid cells, sometimes frankly suppurating in 
 cases of lupus with a rapid course. The question has arisen: is this 
 inflammatory reaction due to a special virulence of the bacillus 
 or to secondary infections? In other cases, there is a fibrous reaction 
 with a tendency to encapsulation of the newformation, more par- 
 ticularly in the forms capable of undergoing absorption. Lupus 
 cicatrices often enclose latent nodules. 
 
 The epidermis is sometimes passive, distended and atrophic, 
 whereas in other cases it proliferates, vegetates and may grow so 
 exuberantly that certain vegetating or papillomatous cases of lupus 
 or framboesiform tuberculosis are suggestive of lupus-epithelioma. 
 In proliferating lupus of an ulcerative appearance, the epidermis is 
 often found to be reduced to its deep layers. 
 
 Lupus is so poor in bacilli that their demonstration discourages 
 the majority of histologists and very few have pursued it to the end. 
 From forty to sixty slides often must be studied before a bacillus 
 is encountered. The human bacillus is responsible for most of the 
 cases. 
 
 Inoculation into guinea-pigs, which react readily, necessitates 
 the injection of at least 50 cgm. of lupus tissue, to be convincing; 
 even under these conditions, it fails in one-third of the cases. The 
 virulence of the bacillus is usually moderate and exceptionally 
 attenuated. The tuberculin test, which is always positive requires 
 doses of yo" of a milligram to 1.5 mgr. 
 
 On the whole, lupus vulgaris is certainly a cutaneous tuberculosis, 
 although in numerous respects it is related to the tuberculides. 
 
 Tuberculides. — The histological lesions of the tuberculides are 
 not uniform in character. Sometimes they have a tubercular 
 structure, like the most positive bacillary tuberculosis, representing 
 what I have named the tubercular type, or Type A; in other cases, 
 they are of ordinary inflammatory character, representing my 
 non-tubercular type B (also named atypical cutaneous tuberculosis 
 by Pautrier, non-tubercular inflammatory tuberculosis, by Gougerot 
 and numerous authors). I was led formerly to believe that the 
 different tuberculides followed one or the other type of lesion, but 
 have since recognized that the two aspects may coexist or succeed 
 one another in the same clinical form. 
 
 At any rate, it is usual to find typical tubercles in lichen scrofulo- 
 sorum, where they are situated at the level of the papillary body; 
 they are also met with in the hypodermic sarcoids and in erythema 
 induratum. 
 
 In the cutaneous sarcoids of Boeck, the infiltration as in some 
 cases of lupus vulgaris and especially in lupus pernio, is composed 
 for the most part of circumscribed collections of epithelioid cells. 
 
TUBERCULOSIS 577 
 
 In the papulonecrotic tuberculides, the initial lesion is a small 
 necrotic focus of the connective tissue which promptly becomes sur- 
 rounded by a reactive inflammatory zone, whose lymphoid and 
 embryonic cells are preferably arranged around the vessels. These 
 more or less deeply situated foci, very superficial in acne cachecti- 
 corum tend to rise and come to lie under the epidermis which is 
 raised by a little serum, finally drying up in small crusts. In acnitis 
 (Darier) and at the terminal stage of the papulonecrotic tuberculides 
 (Brissy), very distinct tubercles may be encountered. 
 
 The essential lesions of lupus erythematodes consist of the 
 following: in the cutis, a diffuse and especially perivascular cellular 
 infiltration, composed of small connective-tissue cells and lympho- 
 cytes; plasmocytes and polynuclears are rare. Audry and Leredde 
 found giant cells, which are of exceptional occurrence and usually 
 associated with a disintegrated hair-follicle. Some bloodvessels 
 are obliterated while others are dilated; small hemorrhagic points, 
 lymphatic dilatations and often edema in the papillary body occur. 
 
 The epidermis is in a state of partial horny atrophy, meaning 
 that its Malpighian layer after at first having been thickened, is 
 now atrophied and locally reduced to one or two rows of deformed 
 cells; its stratum granulosum is missing at numerous points, the 
 horny layer on the contrary is thickened, stratified and penetrates 
 in cones into the sebaceous and sudoriparous pores and into the inter- 
 papillary buds; the last named fact accounting for the clinical sign 
 of "punctate keratosis." 
 
 The disappearance of the elastic and connective-tissue fibers 
 where the infiltration predominates, indicates the mechanism to 
 which the final atrophy is due. The hairs fall out soon. The origin- 
 ally enlarged glands finally disappear. 
 
 Briefly, the condition is an endoperivasculitis with a tendency to 
 atrophy and to hyperkeratotic atrophy of the epidermis. 
 
 Koch's bacilli have been discovered in lichen scrofulosorum 
 (Jacobi and Wolff) and in erythema induratum; with the aid of 
 modern methods, with antiformin or by the Gram-Much procedure, 
 positive results although open to controversy have, moreover, been 
 obtained in nearly all the tuberculides, including lupus erythema- 
 todes. 
 
 In exceptional instances, guinea-pigs have been successfully 
 rendered tuberculous through lichen scrofulosorum (Jacobi, Wolff, 
 Pellizari, Haushalter, Lefebvre), through erythema induratum 
 (Thibierge and Ravaut, C. Fox, Eyre, Carle), and through lupus 
 erythematodes (Gougerot, Br. Block). Inoculation into monkeys 
 is not more apt to be successful. 
 
 The tuberculin test yields inconstant and often not very distinct 
 results, although Jadassohn obtained a positive local and general 
 37 
 
578 INFECTIOUS BACILLARY DERMATOSES 
 
 reaction in 14 of 16 cases of lichen scrofulosorum ; it is also often 
 obtained in erythema induratnm. I was equally successful in the 
 three cases of subcutaneous sarcoids which were examined from this 
 point of view. 
 
 LEPROSY. 
 
 Leprosy (lepra of the Arabs, elephantiasis of the Greeks, spedal- 
 sked of the Norwegians, la lepre of the French, Aussatz of the Ger- 
 mans) is a chronic infectious disease, which develops with periodic 
 exacerbations and is caused by a special microbe, the Hansen 
 bacillus. Numerous and varied cutaneous manifestations occupy 
 a prominent place in the symptomatology of the disease. 
 
 Leprosy seems to have existed from the earliest times among the 
 peoples whose history has come down to us, notably in India, 
 Egypt, Greece (alphos), China, etc. But it was confused with 
 numerous contagious affections, so that the zaarath of the Bible 
 has nothing in common with genuine leprosy (W. Dubreuilh and 
 Bargues). In the middle ages, after the Crusades, it became widely 
 distributed in Europe; numerous leper asylums were erected (over 
 2000 in France) which in all probability erroneously harbored 
 more than one case of tuberculosis or syphilis. 
 
 [Originating in the Orient, leprosy was spread over Europe by 
 the Roman armies and colonizers. There are ample records of its 
 presence in France and England long before the Crusades but that 
 great movement of men to and fro across Europe served to increase 
 the number of cases enormously. In the fourteenth and fifteenth 
 centuries the disease was common throughout the British Isles. 
 Thereafter the epidemic gradually faded and the last autochthonous 
 leper died in the Hebrides about a hundred years ago. The disease 
 was carried to the West Indies, Mexico, Central and South America 
 by the early Spanish settlers and by negro slaves from Africa. It 
 reached the shores of the United States in the same way and more 
 directly from the West Indies. In the Philippines with their large 
 Spanish and Chinese population leprosy has been endemic for 
 several centuries. In the Sandwich Islands it was introduced about 
 the middle of the last century.] 
 
 At the present day this disease is practically extinct in our 
 regions. Autochthonous cases are rare in France, even in Brittany 
 and Provence; Great Britain, Belgium, Switzerland, Germany, 
 Austria, as well as the United States of America, are free from it or 
 have only a few trifling local endemic foci. Lepers are more common 
 in Norway, Italy, Spain and Algeria. In the Balkan Peninsula, 
 in Southern Russia, in the Baltic Provinces and in Iceland, leprosy 
 is fairly common. 
 
 Among the most gravely infected countries, I shall mention 
 
LEPROSY 579 
 
 Hindustan, Persia, China, Indo-China, Japan, Polynesia and not- 
 ably New Caledonia and the Sandwich Islands ; Latin America 
 [including some of the West Indies] may be considered as an 
 important focus; certain parts of Africa are also more or less 
 severely affected. 
 
 [In the United States the largest focus at present is in Louisiana 
 where it has existed since the first settlement. In the middle of the 
 last century a considerable number of cases were imported into the 
 Northwestern States by Scandinavian immigrants, but there has 
 been no increase in these regions; on the Pacific Coast a small 
 focus is due to importation from the Sandwich Islands and the 
 Orient. There are a few sporadic cases in Texas, Florida and 
 South Carolina. In the larger cities, cases are found among the 
 emigrants from Russia, Italy, the West Indies, South America 
 and China.] 
 
 Owing to the facility and increasing frequency of communication, 
 there are numerous opportunities for the importation of lepers into 
 seaports and large cities all over the world. 
 
 The authors to whom we are indebted for most of our knowledge 
 on the subject of leprosy are: Danielssen and Boeck, Sr. (1846), 
 Virchow, Hansen, Neisser, Besnier, Leloir, Lima, Zambaco, Ehlers, 
 Jeanselme, etc. 
 
 Etiology. — Leprosy is a disease of mankind and respects no race, 
 no age, no social station, nor any climate or latitude. 
 
 Leprosy is caused by the bacillus which was discovered by Hansen 
 in 1871 and was more accurately studied and stained by Neisser. 
 It resembles the Koch bacillus, but is shorter, more rigid, less 
 regular in form and much more abundant in the lesions; it is acid- 
 fast and stains by the Ziehl method as well as by the methods of 
 Gram, Weigert and Much. 
 
 It is not certain that real cultures of the Hansen bacillus have so 
 far been obtained; of the positive results reported by numerous 
 authors on more or less complicated culture-media, none have 
 proved universally convincing. 
 
 Inoculation of leprous tissue into all sorts of animals is usually a 
 failure; but Ch. Nicolle, in 1905, apparently succeeded in infecting 
 a Macacus sinicus, in which nodules made their appearance on the 
 sixty-second day. 
 
 The disease known as "rat leprosy," discovered by Stefansky 
 in Odessa in 1903, which is distributed over the entire world, presents 
 in certain respects, notably in the characteristics of its pathogenic 
 agent, analogies with human leprosy, although it also differs from 
 it very essentially. E. Marchoux, who recently investigated its 
 modes of propagation in view of possible deductions applicable to 
 human leprosy, found that it is transmitted especially through 
 
580 INFECTIOUS BACILLARY DERMATOSES 
 
 bites or contact with an erosion, with flies as an accessory factor 
 and perhaps sarcoptes and demodex, but not stinging insects. 
 
 Human leprosy has long been considered as hereditary, although 
 this interpretation still has its advocates, it is not proved by indis- 
 putable facts; on the contrary, the children of lepers are known to 
 remain free from the disease, provided they are removed at birth 
 from the infectious focus. Few births occur among leprous families. 
 
 The contagiousness of leprosy, on the contrary, is unquestionable, 
 but its mechanism is not known and it seems to be subject to certain 
 special conditions. Thus lepers who have been imported into 
 countries free from the disease, for example Paris [or New York], 
 where more than 150 lepers permanently reside, do not establish a 
 local epidemic focus. Nevertheless Frenchmen often contract the 
 disease in countries where leprosy prevails. This fact seems to 
 support the theory of an intermediate host or parasitic carrier of 
 the contagium, such as a mosquito which does not exist everywhere. 
 
 Exceptional but demonstrative cases of transmission are, however, 
 known to have occurred in our countries, like that of Hawtrey 
 Benson's Irishman who was infected after his leprous brother's 
 return from India, whose bed he had shared; or that of Veyrieres' 
 patient who contracted the disease in Nice through her husband. 
 
 In this connection may be mentioned the extremely rapid propa- 
 gation of leprosy in the Hawaiian Islands and in New Caledonia, 
 for instance, where a considerable portion of the population was 
 infected in the course of ten or fifteen years. 
 
 Poverty, dirt, promiscuity and prolonged contact are emphasized 
 as favoring factors of contagion, which is supposed to occur indi- 
 rectly, through the intermediation of clothing or ordinary objects. 
 On the other hand, the presence of ulcerated tubercles, the dis- 
 charge of secretions containing large numbers of bacilli, as is often 
 true for the nasal mucus, the saliva and the genital secretions, 
 serve to render the cases of "open leprosy" more dangerous. How- 
 ever, the portal of entry in the contaminated person is unknown; 
 the nasal fossse in particular, perhaps the digestive tube, the skin, 
 especially the skin of the feet in bare-foot populations, have been 
 considered as possible atria. 
 
 Direct inoculation from man to man, accidental or experimental, 
 is often ineffectual and demands great caution when made in 
 countries where leprosy prevails. But the experiment performed by 
 Arning, in the Hawaiian Islands, on the convict Keanu, in whom 
 leprosy made its first appearance in the vicinity of the inoculated 
 point, leaves little room for doubt. 
 
 The incubation of leprosy has a duration certainly very variable 
 and often very prolonged. 
 
 Its medium duration fluctuates between three and five years; 
 
LEPROSY 581 
 
 sometimes it seems reduced to a few months; often it is prolonged 
 up to ten years and extreme cases have been quoted of fourteen 
 years (Landouzy) and of thirty-two years ( ?) (Hallopeau) . It will 
 be readily understood that the incubation period cannot always be 
 accurately established. 
 
 Symptomatology. — Period of Invasion. — The first manifestations 
 frequently consist of general disturbances of a rather ordinary 
 character. 
 
 Depression, weakness, anemia and somnolence, are practically 
 constant, as well as rheumatoid pains, arthralgias, backache and 
 neuralgias; digestive disturbances are also noted (anorexia, dys- 
 pepsia, coated tongue, transitory diarrheas) headache and vertigo. 
 
 Fever is inconstant and often inconsiderable; but it may assume 
 the form of intermittent attacks with temperatures of 104° and 105°, 
 suggestive of malaria. 
 
 Absence of sweating, or on the contrary attacks of perspiration, 
 severe itching or tingling sensations and a persistent feeling of cold, 
 have also been observed. 
 
 Signs of a certain value are furnished by a dull coloration of the 
 skin of the extremities, sometimes with local asphyxia or syncope; 
 also by obstinate coryza or abnormal dryness of the nasal fossae 
 with recurrent epistaxis occurring without an obvious cause. All 
 these symptoms, the nature of which is often misunderstood, 
 persist during months and years, extending into the subsequent 
 periods. 
 
 According to the tendency of the lesions to manifest themselves 
 especially on the integument or on the nervous system, a distinction 
 is made between tubercular leprosy [lepra tuberosum] and nervous 
 leprosy [lepra nervorum}. 
 
 Macular Period. — No matter what is to be the ultimate form of 
 the disease, but especially in the tubercular form, an established 
 leprosy generally manifests itself by spots or leprides, varying 
 greatly in color, dimensions, abundance and duration, developing 
 in irregular crops. 
 
 They occupy the face, the extremities, the extensor side of the 
 limbs, especially the buttocks and the back. They may assume the 
 appearance of a polymorphous, papular or nodular erythema, with 
 general symptoms, taking a sluggish course. Most commonly they 
 appear in the form of erythemato-pigmentary spots, of variable 
 size (Fig. 174), sometimes simply congestive, or purely achromic 
 or hyperchromic. Although not infrequently pruritic or painful 
 at the onset, they are nearly always characterized by their hypo- 
 esthesia or their anesthesia, which is usually of the thermo-analgesic 
 type. They are diffuse or circumscribed and frequently arranged in 
 circles, rings or serpiginous lines. After the first appearance they 
 
582 
 
 INFECTIOUS BACILLARY DERMA TOSES 
 
 are often ephemeral and may vanish without leaving a trace; later 
 on they become persistent. 
 
 The erythematous spots may cover large areas, simulating ery- 
 sipelas or polymorphous erythema; as a rule, they soon become 
 more or less purplish or bronzed or copper-colored, or less colored 
 than the background in the colored races, and are covered with fine 
 scales; transitory at first, they persist after a recrudescence, spread- 
 ing like a drop of oil and becoming decolorized at the center. The 
 tubercles usually develop upon these spots. 
 
 Fig. 174. 
 
 -Ervthemato-pigmented leprides, in a boy aged cloven years, son of 
 a French official in Cayenne. 
 
 The pure pigmentary or achromic spots, belonging more par- 
 ticularly to the nervous form, present all the above-mentioned shapes 
 and an entire color-scale, from black at one end to pure white at 
 the other. They are often leuko-melanodermic, the center being 
 depigmented and the circumference hyperchromic (morphea leprosa). 
 They may simulate vitiligo (vitiligo gravior), chloasma, pigmentary 
 syphilides, pityriasis versicolor, etc., hut are characterized by their 
 anesthesia. In colored individuals, leprous achromia produces a 
 variety of "piebald negroes." 
 
 The combination with erythematous spots is fairly common and 
 <jives rise to peculiar checkered designs. 
 
LEPROSY 583 
 
 Following the macular period, or in place of it, pemphigus leprosus 
 may occur, being much more commonly observed in the nervous 
 form. It consists of voluminous but not very numerous bulla?, 
 preferably affecting the back of the hands and feet, the elbows and 
 the knees and often the surface of the achromic spots. Evacuation 
 of their clear contents leaves a red or inflamed excoriation which on 
 healing leaves a nacreous anesthetic cicatrix, with pigmented borders, 
 possessing great diagnostic value. 
 
 The crops of bullae recur in the course of the trophoneurotic stage. 
 
 Tubercular leprosy [lepra tuberosum] the tubercular or nodular form 
 of leprosy — or lepre systematise tegumentaire of Leloir — is charac- 
 terized by leprous, tubercles or lepromata. 
 
 A tubercle which remained solitary for several months, has in 
 rare instances been the first manifestation of the disease, as observed 
 by Leloir, Marcano and Wurtz, and Gougerot; by analogy, this has 
 been described as leprous chancre. 
 
 The tubercles are sometimes derived from the slow and partial 
 transformation of erythemato-pigmented leprides; in other cases 
 they develop in crops with abundant lesions, sometimes with febrile 
 or afebrile general disturbances. 
 
 Their vaguely symmetrical localization is approximately that of 
 the spots, with a predilection for the face and ears and possible 
 extension to the mucous membranes. 
 
 Hypodermic lepromata are also observed, perceptible to the 
 touch as circumscribed nodosities or infiltrated and nodular patches 
 (Chapter XIV). 
 
 The leprous tubercles (Fig. 175) and the cutaneous leprous infil- 
 trations have been described elsewhere in this book (p. 258), and 
 I have pointed out their possible termination in leprous morphea 
 and in leprous ulcers. 
 
 There still remains to be traced the picture of the topographical 
 distribution of lepromata. Not infrequently they lend a character- 
 istic appearance to the invaded regions. In the face, this aspect 
 is described as fades leonina or leontiasis leprosa; the forehead is 
 puckered, traversed by deep wrinkles; the region of the eyebrows 
 is thickened and hairless; the nose is deformed, thickened and 
 enlarged; the cheeks, the lips and the chin are lobulated and the 
 beard is reduced to a few thinly scattered hairs. All these surfaces 
 are of a red, brownish or grayish color. In very pronounced cases, 
 the disfigurement is such that the race, age and sex of the patient are 
 no longer recognizable. 
 
 The ears of lepers are typical, with an enlarged auricle studded 
 with tubercles or seamed with cicatrices, a thick, hanging and 
 flabby lobule in which numerous "birdshot" granules are demon- 
 strable on palpation. 
 
:>vi 
 
 INFECTIOUS BACILLARY DERMA TOSKS 
 
 The scalp almost invariably escapes and the luxuriant hair on the 
 head of lepers contrasts with their hairless face and the loss of the 
 body-hairs. 
 
 On the extremities, the elbows, the knees and the prominent 
 portions, including the fingers and toes, are deformed by brownish 
 or purplish tubercles. The integumenl as a whole has a dusky, 
 tawny, earthy, in places cyanotic color, a flabby, withered consist- 
 ence and a peculiar dryness. The nails are dry, brittle and may fall 
 out. In the lower limbs, a pachydermatous condition justifying the 
 name of elephantiasis of the Greeks is not uncommon. 
 
 i^b 
 
 Fi<;. 175. — Leprous tubercles of the lace. Note the alopecia of the eye-brows and 
 interstitial keratitis, with iritis of the left eye. 
 
 Lymph glands are usually enlarged early and may attain an 
 enormous size, without, however, undergoing suppuration. 
 
 Localization on the mucous membranes and on the special sense 
 organs is very common. 
 
 In the nasal fossae, the obstinate bacilliferous coryza and epistaxis 
 of the onset urc followed by lepromata or ulcers of the septum, 
 leading to perforation as in syphilis, with breaking down of the nose. 
 
 The mouth may be the seat of lepromata or cicatrices affecting 
 
LEPROSY 585 
 
 the palate, the velum, the uvula, the pharynx and the back of the 
 tongue. 
 
 The larynx is often attacked at an early date, hence hoarseness 
 of the voice, aphonia, dyspnea after exertion and later on attacks of 
 suffocation. 
 
 The eye is affected with deplorable frequency, especially in its 
 anterior hemisphere. Leprosy here very rapidly gives rise to tuber- 
 cles on the conjunctiva, interstitial keratitis with superficial pannus, 
 episcleritis, iritis; the bacillary infiltration of the iris is sometimes 
 manifested by nodules, almost invariably by exudates which impair 
 vision. The ciliary body is more frequently invaded than the choroid 
 and the retina. Attacks of glaucoma, secondary cataract and 
 atrophy of the eye-ball, may hasten the loss of the eye. 
 
 Visceral leprosy is here only mentioned by name; it affects the 
 lungs, where the differential diagnosis from tuberculosis which some- 
 times complicates it, is not easy but possible by bacteriological 
 methods; the digestive tract, the liver, the spleen, the circulatory 
 apparatus, etc., may also be affected. 
 
 Leprosy of the genital apparatus is common, especially in man. 
 Orchitis leprosa is observed in at least one-third or one-fourth of the 
 cases; it may be acute at the onset; as a rule it is an insidious 
 bilateral orchiepididymitis, of which the patient is not aware; the 
 organ is smooth or nodular, but hard and undergoes atrophy. The 
 lesions lead to early sterility, without loss of libido and later to 
 impotence. Not many data are available on leprosy of the female 
 genital apparatus; its different parts, notably the ovaries, may be 
 damaged and undergo sclerotic atrophic changes; according to 
 Babes, about 70 per cent, of female lepers are sterile. 
 
 The course of tubercular leprosy is very variable; it is rarely acute 
 and fatal in a few months, but usually chronic, lasting ten or twenty 
 years and longer. The attacks are interrupted by prolonged remis- 
 sions, with retrogression of all symptoms, simulating a cure. These 
 remissions are the rule in our countries. When the course is pro- 
 gressive, the ulcerations, the suppuration, the fever and diarrhea 
 lead to marasmus and death, which often occurs as the result of 
 severe local disturbance or a superadded complication. 
 
 Lepra Nervorum. — The second ordinary type of established leprosy 
 is the generalized nervous form or lepra maculo-anesthetica or tropho- 
 neurotica. 
 
 It likewise begins almost invariably with macules; it is not certain 
 that these may be entirely absent. Frequently they are large and 
 perfectly symmetrical; disturbances of pigmentation are marked. 
 The macular stage is sometimes indefinitely prolonged, so that a 
 form of so-called macular leprosy [lepra maculosa] has been described. 
 
 In other cases, the onset of the disease is marked by pemphigus 
 
586 INFECTIOUS BACILLArV DERMATOSES 
 
 leprosus which occurs in attacks sometimes leading to sloughs and 
 frightful mutilations; sonic authors have accordingly recognized a 
 macular and bullous form of the disease, known as Lazarine leprosy. 
 
 As a rule, nerve leprosy is characterized by tumefaction of certain 
 nerves, by anesthesia and by trophic disturbances of the skin, the 
 muscles and the bony framework. 
 
 The nerves accessible to palpation, notably the ulnar nerve above 
 the bend of the elbow, the external popliteal, or the superficial nerves 
 of the cervical plexus or the forearm, are cylindrically thickened or 
 more often the seat of spindle-shaped swellings or beaded nodosities. 
 
 Although painful at first, they soon become insensitive and at the 
 same time cutaneous anesthesia is developed. 
 
 Neuritis manifests itself by neuralgic pains, sometimes intoler- 
 able, circumscribed areas of pain, pruritus unrelieved by scratching, 
 sensations of numbness, "dead fingers," local cyanosis, sudoral 
 disturbances, etc. 
 
 The anesthesia, which possesses great diagnostic value, was care- 
 fully studied by Jeanselme. It particularly affects the extremities 
 symmetrically, first the lower limbs, progressing from the periphery 
 to the center. Band-like at the onset, occupying for instance on 
 the upper extremities the little ringer and the ulnar border as far as 
 the axilla, at the lower limb the big toe and the internal border of 
 the foot and leg, it subsequently assumes a segmentary type. It is 
 variably distributed; outside of the territory where it is established, 
 there exists a movable anesthetic zone, imperfectly bounded by a 
 transitional area; at its origin it is superficial, but shows a tendency 
 to increase in depth. The anesthesia is dissociated; the tempera- 
 ture sense is lost first, next, sensibility to pain disappears and much 
 later the tactile and pressure sensations. Sensory perversions and 
 retarded sensation are not uncommon. Finally the loss of sensation 
 becomes total, at least at the extremities; deep burns may occur, 
 the patient remaining unconscious of them. 
 
 Muscular atrophy affects especially the face and the extremities. 
 In the face, the orbicularis palpebrarum is first attacked, as a rule, 
 causing inability to close the eyes and its sequel*. 
 
 The forehead, the cheeks, the circumference of the mouth are 
 attacked in their turn. The emaciation of the face, the pale and wan 
 complexion, the fixity of the features with lagophthalmos, lend the 
 face a strange appearance, known as "fades Antonina." 
 
 On the hands, the muscular atrophy affecting the thenar and 
 hypothenar eminences as well as the interossei, leads to deformity in 
 the Inn 11 of ulnar Hair, or of boat-shaped hollows on the back of the 
 hand, or to one of the types of chronic rheumatism. It later involves 
 the forearm and especially the extensors and sometimes the upper 
 arm. There is no paralysis but only a diminution in strength pro- 
 
LEPROSY 587 
 
 portionate to the atrophy. On the feet, the plantar muscles are the 
 first to be attacked, but the atrophy of the anterior tibial and the 
 extensors of the toes attract more attention, causing a varus equinus 
 position and a halting gait. 
 
 The bony and articular lesions which are characteristic of lepra 
 mutilans are derived either from penetrating ulcers, or from malum 
 perforans, which is frequent and is distinguished by its depth and 
 total anesthesia, or from panaritium terminating in necrosis, as in 
 Morvan's syndrome; or from dry gangrenes; and often also from 
 bone absorption without external lesion. The foot and the hand 
 may be reduced to irregular stumps which have been compared to 
 elephants' feet (elephantiasis of the Greeks) or to the paws of seals. 
 
 Nerve leprosy takes a slower course and has an even longer 
 duration than tubercular leprosy; it is not uncommon for it to exceed 
 twenty years. In the advanced stages, the condition of the patients 
 is extremely distressing; they are emaciated, mutilated, blinded, 
 paralyzed, suffer from intolerable neuralgias, persistent cold, 
 unquenchable thirst, often from infected ulcers and are sunk in 
 deep apathy, melancholia and marasmus. A toxemic psychosis of 
 lepers has recently been described. Death supervenes through 
 cachexia, purulent infection, pneumonia, diarrhea, nephritis, and 
 occasionally through tuberculosis. 
 
 Mixed Form. — It must be understood that the two preceding 
 pictures of tubercular leprosy and nerve leprosy are more schematic 
 and didactic than in conformity with the ordinary appearances. 
 
 Almost invariably, while one of these groups of symptoms pre- 
 dominates, there occur the most varied associations and com- 
 binations. Mixed or complete leprosy is by far the most common, 
 either from the start or more frequently as a result of modifications 
 in the course of evolution; the tubercular form especially tending 
 to become gradually complicated by nervous and trophic disturb- 
 ances. 
 
 Pathological Anatomy. — Leprous tubercles or lepromata are made up 
 of a sharply limited and very coherent intradermic infiltration, under 
 a normal although stretched epidermis; it is separated from the 
 basal layer by a thin band of normal tissue with a wavy lower border 
 and is prolonged in cuff-form around the vessels, which are affected 
 with endoperi vasculitis and around the nerves, the lesions of which 
 are inconstant, as well as around the glands. 
 
 The infiltration is made up principally of the "lepra cells" of 
 Virchow, large cells with a clear and vacuolated protoplasm, some- 
 times polynuclear; furthermore, by connective-tissue cells, a few 
 lymphocytes, mast-cells and occasional plasmocytes; sometimes 
 giant cells are found. Bacilli are more abundant than in any other 
 microbic disease; they are arranged in clusters or bundles, especially 
 
588 INFECTIOUS BACILLARY DERMATOSES 
 
 in the lepra- and connective-tissue cells and are sometimes extra- 
 cellular and agglomerated in a glairy substance (glcea); the name 
 of globi is applied to balls or strands composed entirely of bacilli. 
 Caseation is not found in lepromas. 
 
 In recent spots or leprides, only perivascular cuffs of round cells 
 are found, which in the course of the successive exacerbations 
 become mixed with lepra-cells at first not very large. The pro- 
 gressive increase and confluence of the perivascular infiltrations 
 lead to the transformation of the spots into tubercles. In opposition 
 to prevailing opinions, I showed in 1897 that there are merely differ- 
 ences in degree between these two lesions and that leprides regularly 
 contain, from their onset, a number of bacilli which although not 
 very considerable can nevertheless be demonstrated by a suitable 
 technic. [In 1899, in Unna's clinic, I was able to demonstrate a few 
 bacilli in the apparently normal skin of a leper after a febrile attack.] 
 
 The cutaneous manifestations of leprosy result from bacillary 
 embolisms. Several authors have noted a bacillemia at the time 
 of the exacerbations, accompanied by polynucleosis; after the 
 crisis a transitory lymphocytosis follows and then a persistent 
 eosinophilia, which is sometimes very marked (over 30 per cent, 
 according to Gaucher and Renaut). 
 
 Leprous neuritis was described by Virchow. When the nerves 
 are involved, they present the changes of parenchymatous and 
 sclerotic neuritis, of peripheral origin and centripetal course, 
 according to Gerlach, Dehio, etc., or with multiple points of attack. 
 Abundant collections of bacilli may be found, especially in the 
 mixed form. 
 
 Diagnosis. — The disturbances of the period of invasion are gener- 
 ally not referred to their true cause until after the appearance of 
 more significant manifestations. 
 
 The question of a possible leprosy most frequently arises in con- 
 nection with erythematous or pigmented spots or even of tubercles, 
 which may be solitary or agminated in lupoid or syphiloid patches; 
 in other cases, attention is aroused by nervous disturbances sug- 
 gestive of polyneuritis, tabes, rheumatism, or especially syringo- 
 myelia, progressive muscular atrophy, scleroderma, Raynaud's 
 disease, etc. The features of these disturbances, for instance 
 anesthesia or thermo-analgesia of the spots or tubercles, may 
 sometimes suggest the diagnosis of leprosy from the start. This 
 supposition will be strengthened by knowledge of the patient's 
 nativity or his sojourn in contaminated countries. The important 
 point is to keep leprosy in mind. 
 
 The impression received should always be controlled by thorough 
 inquiry and by laboratory tests. 
 
 In the first place, the so-called permanent stigmata of leprosy 
 must be looked for; a dusky, cyanotic and pigmented coloration 
 
LEPROSY 589 
 
 of the face and the extremities, with softness and dryness of the 
 skin; alopecia of the beard and body, especially alopecia of the 
 external half of the eyebrows; tubercles of the ear-lobule; tume- 
 faction of the nerves, notably the ulnar nerve; atrophy of the 
 muscles of the hand; anesthesias; scars from bullae on the elbows 
 and knees; leprous orchitis; ocular manifestations such as paresis 
 of the orbicularis, conjunctivitis and episcleritis; rhinitis with 
 hypersecretion and epistaxis, or even perforation of the septum; 
 hoarseness of the voice, etc. 
 
 Absolute scientific proof is furnished by the demonstration of the 
 bacilli. These may be found: by biopsy of a leproma or a lepride, 
 in sections or on a smear preparation of a piece of excised tissue; 
 in default of these procedures, in an extirpated gland, with or with- 
 out the aid of the antiformin method; in the nasal mucus, especi- 
 ally in the tubercular forms after the administration of 4 grams of 
 iodide two days in succession if necessary. 
 
 The intradermo-reaction to leproline, which was tried by Mantoux 
 and Pautrier; also, the sero-agglutination proposed by Gaucher and 
 Abrami; as well as the complement-fixation reaction, with a leproma 
 extract as the antigen; all these are undoubtedly valuable methods, 
 but cannot as yet be described as entirely satisfactory. It must be 
 remembered that the blood serum of lepers, even those free from 
 syphilis, usually yields a positive Wassermann reaction and that 
 eosinophilia is common in their blood. 
 
 Prognosis and Treatment. — As to the curability of leprosy, it must 
 be remembered that prolonged remissions and arrest of the disease 
 which might be considered as cures, have been observed even in 
 countries where leprosy is endemic. 
 
 Moreover, there are incomplete (fruste), benign forms in which 
 the symptoms are reduced to a few spots, circumscribed anesthesias, 
 partial amyotrophies, without any further evolution. A recru- 
 descence, however, is always possible. I have repeatedly observed 
 the redevelopment of a checked leprosy at the time of the patient's 
 return to the land of origin of the disease. In short, the possibility 
 of a cure of leprosy must be conceded, but with reservations. 
 
 The prophylaxis is more important than therapeutic measures. 
 The rule of compulsory reporting of cases and relative isolation of 
 the patients, although harsh in its application, has yielded such 
 brilliant results in Norway (243 cases in 1902, where there were 
 2598 in 1856) that it should be enforced in all contaminated coun- 
 tries with modifications to suit conditions. Occupations which 
 involve the risk of the spreading of the contagion must be forbidden 
 to lepers. 
 
 Persons who come in contact with lepers must practise measures 
 of scrupulous cleanliness and strict personal hygiene. The lepers 
 must be regularly bathed, cleaned and bandaged. As far as possible, 
 
590 INFECTIOUS BACILLARY DERMATOSES 
 
 they must be advised to leave the infected countries and to reside 
 in a healthful temperate climate; under these conditions, lasting 
 improvements and quasi-cures are sometimes observed. 
 
 No medication possesses an absolutely specific value. Mercury 
 in soluble injections, or in the form of calomel or gray oil, seemed 
 to give good results in my experience and in that of ('rocker, Ehlers 
 and Ilaslund. Iehthyol, salol and salicylates have been recom- 
 mended. Treatment with arsenobenzol is useless. The classical 
 treatment, the best on the whole, although its value is disputed, 
 is chaulmoogra oil, given in doses of V drops, progressively increasing 
 to CL and CC, in emulsion or better in capsules, for periods of two 
 months, several times during the year. Given by the mouth, it is 
 often not well tolerated; I have always been pleased with intra- 
 muscular oily injections according to the formula of Brocq (chaul- 
 moogra oil, 70 cm., eucalyptol 30 cm., in sterilized ampoules of 5 
 cm.). Its substitutes, gynocardic acid and gurjun balsam, seem to 
 be less active. Opinions differ concerning the value of nastine 
 injections; the name nastine is applied to products derived from 
 cultures of a streptothrix extracted from lepromata by Deycke; 
 these injections have sometimes proved injurious. 
 
 [There is no doubt that cases of leprosy have been arrested and 
 possibly cured by chaulmoogra oil. The problem is to introduce 
 the remedy in sufficient dosage. Hollmann and Dean (Honolulu) 
 have recently published some very striking results obtained by 
 subcutaneous injections of ethyl esters of chaulmoogra fatty acids.] 
 
 Very hot baths bring great relief and a sense of well-being to 
 lepers, especially in painful cases. 
 
 The tubercles break down and disappear on cauterization with 
 the galvanocautery. The ulcers must be kept very clean and covered 
 with moist aseptic dressings; I have obtained good results from 
 daily painting with Mencieres fluid [therapeutic notes, section 3]. 
 The ocular lesions are benefited by subconjunctival mercurial injec- 
 tions, atropin and warm local douches. 
 
 In a general way, different local measures are required, according 
 to the nature of the lesions and their seat. There is no doubt but 
 that an actively and persistently treated case of leprosy takes an 
 infinitely more favorable course than when the disease is left to itself. 
 
 The future undoubtedly belongs to a serum [or chemotherapeutic] 
 treatment which still remains to be discovered. 
 
 GLANDERS. 
 
 Glanders (French, la morve, German, Rotz) [Malleus] is a very 
 grave contagious and inoculable microbic disease which affects 
 Soliped animals and is transmissible to man. It takes an acute or a 
 
GLANDERS 591 
 
 chronic course. In different cases, the general symptoms, or the 
 visceral lesions or the cutaneous and mucous lesions predominate. 
 
 There is no valid reason for maintaining the formerly made dis- 
 tinction between glanders on the one hand, an internal disease 
 affecting the respiratory apparatus and especially its first passages, 
 the nasal fossae — and farcy on the other, an external disease affecting 
 the skin and hypoderm; for their cause is identical. 
 
 The frequency of glanders in horses and asses had considerably 
 diminished in France before the war, especially since the discovery 
 of malleine, a secretory product of the bacillus, made its early 
 diagnosis possible. 
 
 Human glanders, which is rare, is in the vast majority of the cases 
 of direct equine origin, so that those whose occupation puts them 
 in contact with horses are apt to contract it by cutaneous inocu- 
 lation, without there necessarily existing a demonstrable erosion. 
 It seems probable that infection may also occur through the nasal 
 
 The bacillus of glanders is slender and shows clear spaces [vacuoles?] 
 it does not take the Gram-stain; it can be stained by Weigert's 
 method or by Nicolle's method with tannin, but easily becomes 
 decolorized. Its cultures on potato assume a tawny, then brownish 
 color and are characteristic. It is very dangerous to handle and can 
 be successfully inoculated into all laboratory animals. 
 
 Glanders pus introduced under the guinea-pig's skin gives rise 
 in a few days to a swelling from which culture-material may be 
 extracted; on injection into the peritoneum of a male guinea-pig, it 
 gives rise in three days to a severe orchitis. Straus pointed out the 
 value of the last-mentioned reaction for the diagnosis, but it is 
 not absolutely conclusive. The serum of animals having glanders 
 agglutinates the glanders bacillus at 1 to 500 or 1 to 1000; but 
 agglutinins may also exist in some normal sera. The comple- 
 ment-fixation test is made by means of an extract of bacilli as 
 antigen. 
 
 The anatomical lesions of glanders are characteristic only when 
 they are found to consist of glanders granulations; the latter have 
 been compared to tubercles, but are rather minute abscesses, com- 
 posed principally of polynuclears; they become necrotic and liquefied 
 in their center; a peculiar fragmentation of the nuclei occurs, 
 known as chromatorhexis. 
 
 The clinical forms are multiple and very dissimilar : 
 
 Acute glanders is a blood-infection, a septico-pyemia, which 
 occurs primarily or as the result of cutaneous inoculations (farcy 
 chancre) and sometimes as the termination of the chronic form. 
 It assumes a typhoid or rheumatoid course, or especially that of 
 pyemia, with a remittent, later an irregular fever, great weakness, 
 
592 INFECTIOUS BACILLARY DERMATOSES 
 
 arthritis, respiratory symptoms, a grave general condition; it kills 
 in five to twenty days. 
 
 Its cutaneous manifestations may consist at the onset in an 
 ascending lymphangitis of the limbs promptly followed by abscesses; 
 or in erysipeloid swelling of the face, of dark red color, with diffuse 
 borders, without elevation, on which blisters or sloughs make their 
 appearance; ultimately, after several days, a disseminated pustular 
 eruption develops, resembling variola but not umbilicated and with 
 a tendency to ulceration and gangrene; sometimes, abscesses appear 
 and as they multiply cover the limbs with so-called "farcy-buds," 
 (acute farcy). 
 
 Chronic glanders behaves like a localized infection with a tendency 
 to become generalized in exacerbations. It manifests itself as 
 phagedenic penetrating ulcers and abscesses; these are situated on 
 the face or on the limbs. The clinical picture becomes complicated 
 by general, febrile, articular, testicular, digestive and respiratory 
 disturbances and usually terminates in acute glanders; a cure is rare; 
 as a rule it is merely apparent or temporary. The duration is from 
 eight to fifteen months or sometimes several years. 
 
 Mutilating glanders of the face is the most interesting form for the 
 dermatologist. It begins with tuberculo-ulcerative lesions of the 
 nasal fossae or the buccal mucosa; by extension and by accessory 
 dermic abscesses originating in the vicinity, the ulceration (which 
 has a puckered floor, livid margins and a profuse discharge of yel- 
 lowish pus) reaches the face, destroys the soft portions of the nose, 
 the cheeks, the lips and sometimes the nasal septum, exposing the 
 bones without attacking them; the glands are usually enlarged. 
 Festooned borders, as if gnawed by the teeth of mice, and pustules 
 or aberrant sloughing ulcers are features which should attract 
 attention. Observations concerning this form of glanders are rare 
 (Hallopeau and Jeanselme, Besnier, E. Hoffmann); probably some 
 cases are not recognized. The differential diagnosis is difficult from 
 tertiary or hereditary ulcerative syphilide; lupus vorax; mycoses; 
 [espundia] and other phagedenic affections. Laboratory tests are 
 required for its confirmation. 
 
 Treatment. — There is no specific treatment for glanders at the 
 present time. Treatment with mercury, iodides and arsenobenzol, 
 which have been empirically tried, is without reliable effect. Hence, 
 in cases with a known initial lesion or in chronic ulcers due to glan- 
 ders, the question of excision arises when this is practicable, or of 
 cauterization with the actual cautery. Radiotherapy might serve 
 to dry out the ulcers and inhibit their progress. The abscesses must 
 be immediately incised, scraped and disinfected. But the prognosis 
 is extremely gloomy. 
 
ANTHRAX— MALIGNANT PUSTULE 593 
 
 VERRUGA PERUANA. 
 
 Verruga — also named Carrion's disease or Oroya fever — is a 
 severe infectious, frequently fatal, disease, which is endemic in 
 some Peruvian valleys. 
 
 It begins with septicemic symptoms, an irregular fever with 
 rheumatoid pains; followed at the end of a few weeks or months by 
 an eruption of numerous scarlet red pruritic miliary elevations, which 
 increase in size and become pedunculated. There are also larger 
 warty or fungoid nodosities which appear in variable number. 
 Whether small or large, the lesions are extremely vascular and bleed 
 readily; they have at first the structure of a granuloma, which 
 becomes areolar through marked dilatation of the blood and lymph 
 vessels. The eruption predominates on the face, the neck and the 
 extensor surface of the limbs ; the mucous and serous membranes as 
 well as the viscera may be invaded. 
 
 The pathogenic agent reported by Izquierdo (1885) was redis- 
 covered by Letulle and by M. Nicolle; it is an acid-fast bacillus. 
 Others have looked for it in vain and suspect a special paratyphoid 
 bacillus or a protozoon. Many quadrupeds are susceptible to the 
 disease. Infection is supposed to occur through water or through 
 stinging insects. Verruga confers immunity. 
 
 No specific treatment for the disease is known. 
 
 ANTHRAX— MALIGNANT PUSTULE. 
 
 Malignant pustule is the manifestation of a local inoculation with 
 the bacillus anthracis discovered by Davaine. 
 
 In man, this inoculation almost invariably results from occupa- 
 tional handling of diseased animals, sheep, goats, horses, cattle, etc., 
 or especially of their hides, where the very resistant anthrax spores 
 persist indefinitely. Malignant pustule therefore usually occupies the 
 exposed parts and is observed in shepherds, veterinaries, butchers, 
 tanners, leather-dressers, brush-makers, wool-sorters, workers in 
 horn, etc. [Several cases of infection from shaving-brushes have 
 been reported.] Infection through contaminated flies, often held 
 responsible by the laity, is possible but exceptional. 
 
 Comparable at the onset to a flea-bite, on which a vesicle promptly 
 arises, the pustule becomes indurated and presents a brownish or 
 purplish, granular lenticular spot, which spreads and becomes a 
 slough encircled by vesicles. Itching is rather severe. The circum- 
 ference of the lesion is the seat of a dark red inflammatory edema, 
 sometimes with strands of lymphangitis. The entire region is 
 invaded by a gelatinous infiltration. Finally, the slough is shed, 
 the gangrene increases in depth and in extent, the phenomena of 
 general infection appear; they consist of a high fever, with a weak 
 38 
 
594 INFECTIOUS BACILLARY DERMATOSES 
 
 irregular pulse, difficult respiration, sweats, hemorrhages and 
 delirium; death occurs in collapse. 
 
 The duration of this course varies from twenty-four hours in 
 fulminating cases to twelve or fifteen days. A spontaneous cure is 
 possible, hut must not be expected. 
 
 The name of malignant edema has been employed for a variety in 
 which the central slough is absent; the symptoms consist of a soft 
 swelling with vesicles and of early signs of severe septicemia. 
 Anthrax edema is seen especially on the eyelids or on the lips. 
 
 Treatment. — The old treatment, by excision or cauterization with 
 the actual cautery, is at all promising only on a very recent and still 
 doubtful lesion. Repeated injections, around the pustule, of a 
 carbolized or iodine-iodide solution have been recommended; 
 arsenobenzol has been successfully employed. These measures, 
 however, must make way for serotherapy. Anti-anthracic serum, 
 introduced by Marchoux in 1895, since investigated by Sclavo and 
 others, must be employed in subcutaneous injections of about 40 c.c. 
 and repeated several days until the edema diminishes; it will cure 
 malignant pustule provided it is employed at the onset and even 
 sometimes when the blood-culture is already positive. 
 
 CUTANEOUS DIPHTHERIA. 
 
 Although reported by Chomel and Samuel Bard in the eighteenth 
 century and described by Trousseau, cutaneous diphtheria has 
 become definitely characterized only since the discovery of the 
 Klebs-Loeffler bacillus. It is discussed in numerous publications, 
 of unequal value, the most important being the contributions of 
 Neisser, Schucht, as well as the reviews- of Marchalko, Knowles and 
 Frescoln (1914). It must be distinguished from the ordinary erup- 
 tions of urticaria, erythema and purpura, which are frequently 
 observed in diphtheritic patients, especially in those who have 
 received serum injections. 
 
 Cutaneous diphtheria, due to the growth of the diphtheria 
 bacillus on the skin, is as a rule secondary to involvement of the 
 mucous membranes and the result of auto-inoculation. More 
 interesting, but less common are the cases in which it is primary and 
 exclusively localized on the external integument; these are derived 
 from direct contagion by a diphtheritic patient or a germ-carrier, or 
 from indirect contagion by clothing, bedding, dressings, etc. It 
 must be kept in mind that although diphtheria principally attacks 
 youthful individuals, no period of life escapes the disease. 
 
 Symptoms. — I ndoubtedly the most common clinical form is that 
 beginning with spots or patches of eczematiform dermatitis, situ- 
 ated at the circumference of the orifices of the mucous cavities in 
 which the diphtheria runs its course, for example under the nostrils, 
 
CUTANEOUS DIPHTHERIA 595 
 
 around the mouth, the eyes or ears, and also around the vulva, the 
 prepuce and the anus, Wounds or even the slightest excoriations, 
 located anywhere, impetigo, herpes, cracks, intertrigo and more 
 particularly surfaces which have been denuded by blisters (the 
 danger of which in diphtheria was emphasized by Trousseau), are 
 also very apt to become the seat of diphtheritic infection. 
 
 The infection manifests itself by a serous, turbid or purulent, 
 sometimes fetid exudation with swelling of the affected surface, a 
 purplish reddening and local pain; this surface becomes ulcerated in 
 places; the appearance of a buff -colored false membrane is common, 
 but it may be absent. Extension is rapid at times and sometimes 
 occurs in form of a pseudo-membranous epidermic elevation, with 
 centrifugal extension and polycyclic contours ; or it may result from 
 the coalescence of aberrant vesicular lesions, at other times the patch 
 remains stationary. Fever is not constant; glandular enlargement 
 is usually present; lymphangitis in the vicinity or erysipelas are not 
 uncommon. 
 
 In the primary cases, the objective features assumed by cutaneous 
 diphtheria are very variable. The most ordinary form is that of 
 impetigo, ecthyma or impetiginous eczema analogous with that 
 described above. In other cases, vesicles have been noted resem- 
 bling those of varicella or the vesicle of dermatitis herpetiformis 
 (Dawson), or bullae like those of epidemic pemphigus of the new- 
 born or ulcers with distinctly circulate margins, abscesses and 
 gangrenous patches; exceptionally the lesions may be of different 
 types in the same patient. 
 
 In connection with this polymorphism, it is noteworthy that 
 cutaneous diphtheria is often not pure, either because it becomes 
 grafted on a preliminary skin affection which has served as the 
 infection-atrium, or because the diphtheria bacillus becomes asso- 
 ciated with other microbes, notably streptococci and staphylococci 
 as is commonly the case. Hence, even since the introduction of 
 serotherapy, cases of cutaneous diphtheria with a fatal outcome 
 are not very rare. 
 
 Diagnosis. — Epidemiological factors, or the coexistence in the 
 patient of a lesion of the neighboring mucous membranes, con- 
 junctivitis, otorrhea, rhinitis, erosions of the buccal commissures, 
 angina even if indefinite, vulvitis and balanitis, must arouse atten- 
 tion. The demonstration of a false membrane on a dermic lesion 
 is far from being conclusive. The key to the diagnosis is really 
 furnished by the demonstration of the specific bacillus in smear- 
 preparations, in cultures and by inoculation into guinea-pigs. 
 
 The Loeffler bacillus is generally long, straight or slightly curved, 
 in intermingled rods; it is Gram-positive; at its swollen extremities 
 it presents metachromatic polar corpuscles, staining by the Neisser 
 method; cultures on beef serum, at 98°, yield papular colonies of a 
 
596 INFECTIOUS BACILLARY DERMATOSES 
 
 grayish white color in eighteen to twenty-four hours; it acidifies 
 glucose culture-media; inoculated into guinea-pigs, it causes death 
 in twenty-four to seventy-two hours. 
 
 The pseudo-diphtheritic bacillus of Hofmann, from which it must 
 be distinguished, is shorter, ovoid, has no distinct polar bodies, does 
 not acidify glucose media and, most important, does not kill guinea- 
 pigs. The fusiform bacillus of Vincent is Gram-negative. 
 
 Treatment. — Even in merely suspicious cases, pending the diag- 
 nosis, prophylactic measures for the avoidance of contagion are in 
 order. The injections of antidiphtheritic serum have entirely 
 changed the prognosis of diphtheria; large doses should accordingly 
 be employed. As an accessory measure, the lesions must be carefully 
 cleansed and local applications be made in conformity with the 
 dermatological type and with the supposed microbic associations. 
 The physician will accordingly prescribe for example, in a given 
 case local applications of hydrogen peroxide water, or strong dis- 
 infectants; moist antiseptic or rather cytophylactic dressings, or 
 dressings with polyvalent serum, etc. 
 
 SOFT CHANCRE. 
 
 Soft chancre, simple chancre, or chancroid [ulcus molle] is a specific 
 and contagious ulceration due to inoculation of the bacillus dis- 
 covered by Ducrey (1899) and investigated by Krefting, Unna, 
 Xicolle, etc. This bacillus is a short rod with rounded extremities, 
 which appears separately, in groups, or frequently in small chains, 
 whence the name of streptobacillus; it is stained with carbol blue, 
 dilute Ziehl's solution, etc.; it is Gram-negative; often only its two 
 extremities take the stain. Its culture requires special conditions 
 and was for the first time successfully obtained by Langlet on a 
 medium made of peptonized human skin; Besancon, Griffon and 
 Le Sourd obtained cultures on blood-agar. The streptobacillus can 
 be inoculated into various species of apes. It possesses a striking 
 resemblance to the bacillus of bubonic plague. 
 
 Soft chancre almost invariably results from direct venereal con- 
 tagion, through the deposit of chancroid pus on some traumatic or 
 pathological erosion during sexual intercourse; more rarely it is 
 derived from an indirect contagion. 
 
 The frequency of soft chancres in the same country or the same 
 city is subject to very considerable fluctuations. A preceding 
 attack confers no immunity, as illustrated by countless positive 
 inoculations which have been obtained on the same individual. At 
 the time when the single or dual character of chancre virus was still 
 a matter of controversy, erroneous hopes were entertained of a 
 possible vaccination against syphilis by means of this so-called 
 syphilization method. 
 
SOFT CHANCRE 597 
 
 The bacillus grows at the site of the infection, or inoculation for 
 diagnostic purposes in doubtful cases, the lesions developing without 
 any incubation, they are already characteristic at the end of twenty- 
 four or forty-eight hours or three days at most. 
 
 An incipient chancre presents the appearance of a vesicopustule 
 with an inflammatory areola; on removal of its covering, a conical 
 ulceration is exposed which penetrates deeply into the cutis. Spon- 
 taneous auto-inoculations, notably on the labia majora and in the 
 intergluteal fold often manifest themselves as small perifollicular 
 pustules which have been named chancroidal folliculitis or miliary 
 chancres. 
 
 Papular chancre is a rare variety, but useful to know; it appears 
 as a flattened or slightly acuminate papule with a soft base. 
 Papular chancres are often multiple and may disappear after a short 
 time, or they may become crested with a vesicopustule followed by 
 ulceration. In the folds of the vulva and anus, simple chancres may 
 assume the form of ulcerative and suppurating fissures. 
 
 The mature chancre (p. 281) rarely attains or exceeds the size 
 of a 5-cent piece. At the end of a period varying from two to six 
 weeks, it loses its virulence, discharges less abundantly, granulates 
 and heals spontaneously. Exceptionally, soft chancres are met with 
 which persist several months without progressing and seem to be of 
 attenuated virulence although still capable of auto-inoculation. 
 Soft chancre always leaves a cicatrix with sinuous outlines, which 
 may be smooth or honeycombed. 
 
 No general disturbances from chancroidal infection are known, 
 the disease being purely local. However, various complications 
 may occur. The most common of these is suppurating chancroidal 
 bubo; walking, fatigue and absence of local cleanliness are predis- 
 posing factors. From the onset, during the course, or even after 
 cicatrization of the chancre, the corresponding gland becomes 
 swollen, the tissues are congested, fluctuation may appear and unless 
 treated, spontaneous rupture takes place through a dark red and 
 thinned skin. The pus of this bubo, contrary to the view of Straus, 
 is virulent from the beginning and contains the bacillus. Sponta- 
 neous ulceration of a bubo ordinarily assumes a chancroidal character, 
 that is, the skin becomes detached and sinuous burrows as well as 
 secondary fistulas are formed. This likewise occurs, although less 
 frequently, in case of surgical incision. 
 
 Gangrene of the prepuce and a portion of the sheath of the penis 
 is occasionally observed in the course of subpreputial chancres. 
 
 At the anus, soft chancre generally gives rise to an elevated con- 
 dyloma (chancre in the form of pages of a book) ; it may invade the 
 anal canal (chancroidal anitis of Ravaut and Bord, 1909), causing 
 painful and bloody stools. 
 
 Phagedena is a rare but formidable complication (p. 293). 
 
598 INFECTIOUS BAClLLARY DERMATOSES 
 
 Histology shows soft chancres to consist of a loss of substance of 
 the epidermis and the cutis; it is covered with a layer of pus contain- 
 ing streptobacilli; it presents radiating processes which fissure the 
 floor and the borders. Beyond this layer is a dense infiltration of 
 well developed plasma cells. The bloodvessels show very pro- 
 nounced changes of endoperivasculitis. The lymphatics are dilated. 
 The ulceration results from a sort of digestion of the tissues under 
 the influence of the parasite. 
 
 If the treatment of soft chancre is to he efficient, it must not 
 be limited to applying a little iodoform or a caustic agent to its 
 surface. The ulcer must first be cleansed every day and carefully 
 dressed; this is accomplished by means of cotton wipes or rolls 
 dipped in soapy water, alcohol, or benzine and not until then 
 is the alterative topical agent to be applied. The best is iodoform 
 as a powder or iodoform with an addition of camphor (2 to 5 
 per cent.); it rarely causes dermatitis provided care be taken to 
 deposit it only in the ulceration itself; its persistent and suggestive 
 odor has led many physicians to employ substitutes (iodol, diiodo- 
 form, aristol, europhen, airol, etc.), but none is so efficient. The odor 
 of iodoform can be concealed to some extent by an addition of 
 coumarin or even of powdered roasted coffee beans. Almost equally 
 valuable is silver nitrate in aqueous solution (1 to 15), in customary 
 usage; or pure liquid carbolic acid which may be used only with 
 extreme caution; carbolic acid has also been recommended, in 
 alcoholic solution (10 per cent.), as well as ferropotassic tartrate 
 (15 per cent.) and potassium permanganate (from 2 to 4 per cent.). 
 The borohypochlorite powder of Vincent seems to be greatly supe- 
 rior. A small cotton dressing must be applied. 
 
 The virulence of the streptobacillus is destroyed by heat, so that 
 very hot local baths should be prescribed, to be repeated at least 
 two or three times a day, or preputial irrigations, or continuous 
 applications of compresses soaked in hot boiled water (42° to 45°). 
 Audry recommends the employment of radiant heat of the thermo- 
 cautery brought within a few millimeters of the ulceration until its 
 surface is dried out. A superheated air apparatus is still more con- 
 venient. This procedure, which should be carried out two or three 
 times, is somewhat painful but very effective. 
 
 Suppurating chancroidal bubos are sometimes aborted under the 
 influence of rest in bed, hot compresses and compression bandages. 
 In case rupture appears inevitable, a careful incision may be made or, 
 better, filiform drainage with two threads established; irrigations are 
 applied every day until the discharge becomes merely serous, using 
 a silver nitrate solution (1 per cent.) or a suspension of iodoform. 
 Chancre of the anus is treated by means of wicks covered with a 
 layer of iodoform-vaseline. 
 
CHAPTER XXVIII. 
 DERMATOMYCOSES. 
 
 The name of dermatomycoses must be reserved for diseases 
 developing in the skin or reaching the cutis secondarily and caused 
 by vegetable parasites of a higher order in the scale than the schizo- 
 mycetes or bacteria. I separate these from the epidermomy coses 
 which have already been discussed (Chapter XXV). 
 
 After actinomycosis (the first known type in this category) and 
 Madura foot, which is related to it, the investigations of American, 
 French and German observers revealed the blastomycoses, and 
 finally the sporotrichoses, discovered in America, studied more 
 particularly in France in the last ten years and found in nearly all 
 the countries of the earth. 
 
 It is an established fact that the place occupied by the mycotic 
 infections in human and animal pathology is decidedly larger than 
 was formerly believed. Their knowledge is not only of scientific 
 interest but also possesses considerable practical and therapeutic 
 importance. 
 
 The clinical manifestations of the dermatomycoses are poly- 
 morphous and often ambiguous; laboratory investigations, notably 
 cultures, are indispensable for a positive diagnosis and for identifi- 
 cation of the pathogenic agent. This explains why our acquisitions 
 in this domain are of relatively recent date and as yet incomplete. 
 Moreover, it has been recognized that almost identical clinical 
 pictures may be produced by different species, while inversely para- 
 sites of the same group give rise to dissimilar affections. Accord- 
 ingly there is no conformity between the pathology and the botanical 
 classification. The latter is moreover still in the tentative stage in 
 regard to the lower fungi and not definitely established. 
 
 The following according to E. Pinoy are the botanical groups from 
 which the principal dermatomycoses are derived: 
 
 Nocardia (actinomycoses, mycetomas) ; Cohnistreptothrix (actino- 
 mycosis); cryptococcus (blastomycoses); oidium (blastomycoses); 
 madurella (mycetomas); sporotrichum (sporotrichoses); sacchar- 
 myces (blastomycoses); and aspergillus (mycetomas). 
 
 ACTINOMYCOSIS. 
 
 The parasite which causes so-called "lumpy jaw" in cattle, known 
 in France as sarcoma of the bovine maxilla, was named actinomyces 
 
000 
 
 DERMATOMYCOSES 
 
 by Bollinger. It gives rise in man to suppurating neoplasms and 
 gummous formations. It appears in the pus or in the tissues in the 
 form of yellow granules, from T V to 1 mm. in diameter, opaque and 
 of oily consistence; they can be seen with the naked eye in pus which 
 has been crushed between two glass slides or diluted with water in a 
 watch-glass. These granules are mulberry-shaped and composed 
 of a fragmented feltwork of mycelium in their center from 1 to 2 /x 
 in width and at the periphery by large club-shaped refractive 
 swellings, resulting from degeneration of the filaments, arranged in 
 contiguous rays (Fig. 170). These clubs are sometimes absent. 
 Unlike the mycelium, thev do not stain by the Gram method and are 
 
 
 _sa_ 
 
 Fig. 176. — Actinomyces granule. After Pinoy, Bull, de 1'Inst. Pasteur, November 
 15 and 30, 1913, xi. 
 
 not present in the cultures. The latter show that two distinct species 
 may be involved, differing in their cultures; either Nocardia bovis, 
 growing readily, aerobic, not inoculable into animals; or Cohni- 
 streptothrix Israeli, anaerobic, growing with difficulty and inoculable 
 into the peritoneum of guinea-pigs and rabbits. 
 
 Actinomyces live quite abundantly as saprophytes outside of the 
 animal tissues. Alan is rarely attacked through contagion from 
 herbivorous animals; as a rule he becomes infected in the same way 
 as cattle, notably through grains of cereals which have wounded the 
 skin or the mucous membranes or been carelessly swallowed. The 
 habit of chewing herbs or bits of straw when strolling through the 
 fields must be regarded as dangerous from this point of view. 
 
ACTINOMYCOSIS 
 
 601 
 
 Actinomycosis exists in all countries. In France, its relative 
 frequency in the vicinity of Lyons was pointed out by Poncet, in the 
 region of Bordeaux by Petzes. It is more common in Germany [and 
 rather rare in America]. 
 
 Clinical Forms. — Cutaneous actinomycosis, which alone is here 
 considered, may be primary or secondary; that is, the skin affords the 
 parasite an avenue of entrance which is rare, or of exit, which is 
 frequent. The lesions are cervico-facial in at least two-thirds of the 
 cases, or they may be thoracic or abdominal, or located at the anus 
 or on the extremities. 
 
 Fig. 177. — Actinomycosis of the cheek. 
 
 At the onset there is a hypodermic nodosity, with a rose-colored, 
 hardly painful deeply adherent surface; the center of the mass 
 promptly softens and becomes fluctuating; the purplish skin gives 
 way and permits the escape of a small amount of purulent or 
 sanious fluid, containing yellow granules. At the same time, other 
 nodules have formed nearby which collect into patches and follow 
 the same course; the ulcerations remain fistulous and granulating. 
 (Fig. 177). 
 
 There is presumptive evidence of actinomycosis when lesions 
 presenting the following clinical features are encountered : nodosity 
 
602 DERMA TOM YCO&M& 
 
 followed by a Conglomerate tumor of woody hardness, often deeply 
 adherent, with a purplish surface, containing foci of a slowly gather- 
 ing gummous pus; absence of corresponding glandular enlargement; 
 tendency of the newfonnation to invade all tissues indiscriminately, 
 the muscles, the vessels and even the hones. 
 
 These characteristic features usually suffice for the differential 
 diagnosis from dental abscesses, chancroids, lupus and tubercu- 
 losis verrucosa, tuberculo-gummous syphilides, epithelioma, sporo- 
 trichosis, etc. The demonstration of the yellow granules will supph' 
 the necessary confirmation. Sero-agglutination and the fixation test 
 have yielded results, but these are not reliable. 
 
 Pathological Anatomy. — The parasite stimulates leukocytosis and 
 proliferation of the fixed constituents in the form of nodules. The 
 latter are accordingly formed in their center of an actinomyces 
 granule in an amorphous necrotic zone, often surrounded by a 
 wreath of giant cells; next by a zone of plasma or epithelioid cells; at 
 the circumference there is a more or less considerable infiltration of 
 leukocytes and swollen connective-tissue cells which insinuates itself 
 between the connective-tissue bundles. The last-mentioned zone is 
 of fibro-sarcomatous appearance and of a hard or lardaceous con- 
 sistence. The vessels are often intact. 
 
 Treatment. — Medication with potassium iodide, introduced by 
 Thomassen, has markedly improved the otherwise very gloomy 
 prognosis of actinomycosis. Failures do occur, however. The cus- 
 tomary dose is at least 6 grams daily; Pinoy recommends in addition 
 a salt-free diet and multiple deep cauterization of the lesions. In 
 recent and not very extensive cases, a cure may be obtained in a 
 few weeks. Local iodide injections are also administered. Radio- 
 therapy seemed to me to exert an evidently favorable effect. 
 
 Long-standing, deep and complicated cases require daily doses of 
 to 12 grams of iodide and moreover the surgical removal or curet- 
 ting of the foci. 
 
 MYCETOMA OR MADURA FOOT. 
 
 This disease, which is endemic in India, Western Africa, Morocco, 
 etc., is due to several species of mucedinese, which penetrate into the 
 organism by means of a foreign body such as thorns or splinters of 
 wood, especially in bare-foot natives. The forms of nocardia, 
 madurella mycetomi and Tozeuri have been recognized; Ch. Xicolle 
 grew cultures of an aspergillus inoculable into pigeons (Pinoy). An 
 analogous affection has been observed in America. 
 
 Beginning on the sole of the foot, nodosities make their appear- 
 ance which soften and discharge a sanious fluid containing granules 
 of parasites; these granules are white, red or black, which has led to 
 
BLASTOMYCOSES 603 
 
 three varieties of mycetoma being described. They consist of a 
 mycelial feltwork without clubs. Through the growth and multi- 
 plication of the nodes, the foot becomes deformed, globular and 
 assumes an elephantiastic appearance while covered at the same 
 time with bulla? or tubercles and hollowed by fistulous tracts; the 
 leg on the other hand becomes wasted and atrophic. The glands 
 are rarely enlarged. 
 
 Iodide is not particularly successful and must be reinforced by a 
 salt-free diet and cauterizations. The condition is relieved by the 
 hyperthermic baths advocated by Legrain. Curative treatment 
 must be surgical. 
 
 BLASTOMYCOSES. 
 
 Under this heading diseases are classified which are due either to 
 yeasts or saccharomycetes or to parasites belonging to other botanical 
 groups but which under certain conditions present themselves in the 
 form of proliferating buds like the yeasts; the exact determination 
 of the latter has not always been possible. 
 
 The clinical appearance of the blastomycoses is very polymor- 
 phous. To illustrate these cases, I shall limit myself to outlining 
 the symptomatology of two of the best known types of the disease : 
 
 1. Busse-Buschke Type. — This extremely rare type was very thor- 
 oughly investigated and described by the authors whose names it 
 bears; the cases of Ormsby-Miller, Curtis and Hudelo are appar- 
 ently closely related to it. The pathogenic agent is probably a 
 saccharomyees. 
 
 The condition at the onset is marked by osseous and articular 
 lesions; later on, or sometimes from the start, follicular inflammations 
 develop or more often disseminated gummous nodules which become 
 transformed into ulcers; their purulent contents and fungosities 
 contain yeasts capable of cultivation and inoculation. The disease 
 is febrile, taking a rather rapid course; the general health is gravely 
 impaired. Death results from glandular and visceral lesions,. 
 
 2. Gilchrist Type. — This form is said to be less uncommon; it 
 was pointed out by Wernicke (1892), then by Gilchrist and Ricketts 
 (1896) and was at first attributed to protozoa. About forty observa- 
 tions have been published, the majority in America (Hyde, Mont- 
 gomery, Stelwagon, etc.), and only five or six in Europe. The name 
 of blastomycetic dermatitis is often applied to it. These dermatitides 
 are due to two parasites which present a different appearance in the 
 sections : an oidium Gilchristi in form of a yeast and a parasite with 
 multiple external buds, coccidioides immitis. 
 
 The lesions are dermic and begin on one of the extremities or on the 
 face. A hard, reddish, superficial nodule becomes crusted with a 
 
604 
 
 DERMATOMYCOSES 
 
 yellow point and is transformed into a pustule discharging a thick 
 viscid pus. The miliary abscesses increase in number, extend and 
 give rise to an irregular, circumscribed papillomatous, erosive patch, 
 infiltrated but movable on the deeper layers. The vegetating sur- 
 face is interspersed with miliary abscesses, sometimes covered with 
 crusts and may become partially cicatrized. The lesion extends 
 superficially and the foci often multiply. The duration has fre- 
 quently been from two to three years or longer. Spontaneous cure 
 may occur ( Figs. ITS and 179). 
 
 
 ^ 
 
 
 
 
 
 jj 
 
 ■ >sp 
 
 
 mm 
 
 
 
 
 Fi< 
 
 Fig. 178 Fig. 179 
 
 178 and 179. — Clinical types of cutaneous blastomycosis. (Ormsby.) 
 
 Etiology. Without being as rare in Europe and notably in France 
 as was formerly assumed, the various blastomycoses are nevertheless 
 of very infrequent occurrence. In the lesions the parasites are seen 
 as rounded bodies, measuring about 10/z, composed of a membrane 
 with double contours and granular contents. They are more or less 
 abundant in the sections and may be stained by the Gram-Weigert 
 or other methods. Pus-smears should be washed in ether and 
 examined in a solution of potash. 
 
 The cultures in some cases grow readily on various media, notably 
 on peptone-agar with glucose or maltose, preferably in the incu- 
 bator; in other cases, they are only obtained with difficulty (Gil- 
 christ type). The appearance of the colonies is variable and not 
 very characteristic. The saccharomyces remain in the state of 
 spherical or budding bodies of 2 jx to 20 fj, diameter; the oidia form 
 mycelial-filaments in their cultures. 
 
 Inoculation of some yeasts is successful in mice, young guinea- 
 pigs and sometimes in dogs, yielding a sort of pseudotuberculosis. 
 
SPOROTRICHOSES 605 
 
 Man can certainly be infected through the skin and perhaps also in 
 other ways. It must not be overlooked that various species of 
 mucedinese may be found accidentally on the skin or may live there 
 as saprophytes; they may secondarily infect pathological lesions of 
 various kinds. Great caution is therefore necessary in the inter- 
 pretation of their pathogenic value. 
 
 The several serodiagnostic tests which have been tried do not 
 yield constant or altogether reliable results. 
 
 Pathological Anatomy. — In the first-named clinical type, there 
 exists a granulation-tissue rich in vacuolated giant cells packed with 
 parasites. 
 
 In the pustulo-vegetative type, intra-epidermic abscesses are 
 demonstrable and in the cutis a superficial infiltration is seen formed 
 by various cells, notably plasmocytes with rare giant cells. The 
 proliferating epidermis sends branching proliferations hollowed by 
 miliary abscesses into the depth of the tissue. In a general way, 
 the appearance resembles both tuberculosis and epithelioma. The 
 parasites are scattered and are found especially in the abscesses. 
 
 Diagnosis. — Vegetative syphilides are less irregular in form and 
 have fewer miliary abscesses. Papillary epithelioma has a hard 
 consistence, friable proliferations and whitish masses formed of 
 epithelial cells. The resemblance to tuberculosis verrucosa may be 
 perfect; Gilchrist described his case as pseudolupus verrucosus. 
 The blastomycoses are perhaps less purplish and less painful, more 
 extensive and with more numerous foci. 
 
 In suspected cases, aside from examinations of the pus, biopsy 
 and cultures, it is advisable to inoculate guinea-pigs for the discovery 
 of tuberculosis and to perform the Wassermann test for the elimina- 
 tion of syphilis. 
 
 Treatment. — The blastomycoses are grave affections requiring 
 energetic treatment. Iodides have proved remarkably successful 
 but must be given in large doses, from 6 to 8 grams daily and long 
 continued. Local surgical treatment is sometimes imperative. 
 Dressings with iodine solutions should be applied. 
 
 SPOROTRICHOSES. 
 
 The sporotrichoses are by far the most frequent dermatomy coses. 
 
 For the first reported cases credit is due to Schenk (1899) and 
 Hektoen and Perkins (1900) ; but for our knowledge of the mycoses 
 in general and sporotrichosis in particular in all its forms we are 
 indebted mainly to French contributions, particularly those of 
 de Beurmann with Ramond (1903) and especially with Gougerot 
 (1906-1912) whose work drew attention to this subject. 
 
 The sporotricha are mucedinese, namely lower filamentous fungi. 
 
606 DERMATOMYCOSES 
 
 with a creeping, regular, branching, partitioned or continuous 
 mycelium bearing numerous short sporulated branches. The spores, 
 measuring from .'J to <»m originate separately or in groups of two, 
 either on the filaments or more abundantly on the conidiophorous 
 branches. It is not known if these parasites do not possess higher 
 fructification-forms. 
 
 Among the pathogenic species, the best known and the most 
 frequent is the sporotrichum Beurmanni, which I shall utilize as the 
 type, the sporotrichum Schenckii differing from it in its faintly 
 colored or white cultures and various other features; the sporo- 
 trichum Dori is readily distinguished from it. 
 
 The culture method is the procedure of choice for the demonstra- 
 tion of these organisms; the technic of de Beurmann and Gougerot 
 is simple and easy. Streaks of the pus on unsealed peptone-glucose 
 agar tubes at room temperature yield at the end of six or eight 
 days visible cultures which by the twelfth day have become exuber- 
 ant and are often pure from the start. The method of Gougerot, 
 which consists in dropping some of the pus on the glass of the tube 
 or on the border of the agar, often permits a rapid diagnosis, in two 
 or three days, by the demonstration of small gray filamentous stars, 
 visible to the naked eye, or with the microscope through the culture 
 tube; incubated at 98° the growth is less abundant. Other culture- 
 media, notably carrots with glycerine, may be utilized. The whitish 
 and acuminate colonies gradually turn brown, spread out and 
 convolute on their margins, which are surrounded by a flat, finely 
 radiating areola. These chocolate-brown cultures are characteristic. 
 
 Inoculations into animals have yielded inconstant results; the 
 virulence is slight. De Beurmann and Gougerot have obtained 
 systemic infections; mice are the most suitable animals. 
 
 The portals of entry in man escape observation; sometimes a 
 previous traumatism has been noted at the affected point; infec- 
 tion seems to occur especially by way of the mouth. [A laboratory 
 worker in Chicago was accidently infected on the conjunctiva.] 
 
 Symptoms. — The sporotrichoses are in the highest degree syphiloid 
 or tuberculoid. However, their tissue and their pus are not inocul- 
 able into adult guinea-pigs, which are susceptible to tuberculosis; 
 they are not influenced by mercurial treatment; left untreated, they 
 persist and multiply, whereas they are often readily curable by iodide 
 t reatment ; finally, they contain a special parasite. This combination 
 of features suffices for their recognition as a distinct entity. 
 
 The disease is extremely polymorphous in its manifestations; the 
 following are the principal clinical types: 
 
 I. The disseminated gummems form; the gummas (p. 270) maybe 
 softened but not ulcerated; or ulcerative, ulcero-vegetative, ecthy- 
 matiform; they may assume to the highest degree a syphiloid or 
 
SPOROTRICHOSES 607 
 
 tuberculoid appearance; or in other cases that of large more or less 
 multiple abscesses. 
 
 2. Lymphangitic form (Fig. 180), consisting of lesions of the pre- 
 ceding type in chain-like arrangement above an initial "sporo- 
 trichotic chancre;" this form is encountered especially on the limbs 
 and sometimes on the head. 
 
 3. Extracutaneous forms, affecting the bones, the synovial mem- 
 branes, the testicles and the viscera; it is especially useful to be 
 familiar with primary sporotrichotic osteitis which has been not 
 infrequently observed, for example on the calcaneum; it gives rise 
 to bone-liquefying abscesses and then to fistulas with secondary 
 cutaneous lesions. 
 
 Fig. 180. — Sporotrichosis, lymphangitic form; of two and a half years' standing; 
 positive culture; cure in three weeks by potassium iodide. 
 
 4. Ulcerative forms of the mucous membranes, localized in the 
 mouth or pharynx, may extend to the base of the tongue, the larynx 
 and the trachea; these cases are rare but extremely grave. Sporo- 
 trichotic ulcers of the mucous membranes are distinguished by their 
 prominence, their dirty yellowish-gray color, the absence of false 
 membranes on their surface, their tendency toward diffusion rather 
 than deep destruction and mutilation. 
 
 Sporotrichotic cicatrices resemble those of syphilitic or tuber- 
 culous ulcers; their borders are often irregular and ragged, some- 
 times showing loosely joined tongue-like processes. 
 
 Diagnosis. — The clinical picture may furnish highly suggestive 
 evidence; in the St. Louis Hospital, sporotrichosis is usually recog- 
 nized at first sight. The diagnosis is based on: the multiplicity 
 and polymorphism of the lesions, which taken as a whole justify a 
 diagnosis neither of tuberculosis nor of syphilis; their more acute 
 course than that of the cutaneous tuberculoses; the viscid whitish 
 pus which escapes from the softened nodules; the inconstancy of 
 
608 DERMATOMYCOSES 
 
 glandular enlargements; and the preservation of good general 
 health. 
 
 Two scientific diagnostic procedures are available, however, 
 which are indispensable in doubtful cases, which are very common: 
 (1) Culture, which requires from eight to twelve days; (2) sporo- 
 agglutination, discovered by Widal and Abrami, which furnishes 
 immediate information; it is of value only when positive and at a 
 very high ratio, at least 1 to 200. The serum of patients suffering 
 from actinomycosis or thrush, etc., may also agglutinate a sporo- 
 trichum culture, but at a greatly lower ratio. 
 
 The reactions after cutaneous or subcutaneous injection of sporo- 
 trichum emulsion may confirm the diagnosis, but do not establish 
 it by themselves alone, on account of the possibility of associated 
 reactions due to other mycoses or even to the presence of simple 
 saprophitic yeasts in the patient's throat. It goes without saying 
 that a negative Wassermann reaction, proving the probable absence 
 of syphilis and the negative outcome of inoculation of diseased 
 tissue into guinea-pigs, showing the absence of the Koch bacillus, 
 are signs indirectly capable of corroborating a suspicion of mycosis, 
 but insufficient for the determination of the special agent. 
 
 Pathological Anatomy. — The histological lesions of the sporo- 
 trichoses are not more characteristic than their clinical appearance. 
 They consist of a nodular inflammation with a suppurative center. 
 
 According to the general formula of Gougerot, the sporotrichotic 
 nodule is formed by three concentric zones: at the periphery it is 
 syphiloid, due to its subacute perivascular inflammatory character, 
 with inconstant connective-tissue reaction and mononucleosis with 
 plasmocytes; the middle zone is tuberculoid, through its epithelioid 
 tubercles arranged around giant cells; the center is suppurative, 
 with polynuclear and macrophagic cells. The majority of the 
 tubercles originate from a proliferation of the vascular walls. 
 
 One must not expect to find branching and spore-bearing myce- 
 lium in the sections or in the pus; the only findings, which are more- 
 over not constant, are short filaments or rather " navicular" bodies, 
 free or contained in phagocytes. 
 
 Prognosis and Treatment. — Left untreated, the sporotrichoses 
 persist and their foci increase in number. Under the influence of 
 iodides they are curable in the vast majority of the cases in the space 
 of a fortnight to two months. The non-ulcerated forms subside 
 more rapidly than the others. The existence of a tuberculous or 
 other cachexia, to which the sporotrichosis may be secondary, of 
 course aggravates the prognosis. The case observed by Letulle- 
 Debre [pharynx, etc.] terminated in death. 
 
 Potassium iodide should be administered in daily doses of 5 or 6 
 grams, or more if tolerated by the patient; it is advantageous to 
 
SPOROTRICHOSES 609 
 
 combine with it a salt-free diet; other iodides or injections of iodized 
 oil may be utilized as substitutes in case of intolerance. Locally, 
 it is necessary to puncture the purulent collections and to inject 
 them with a 1 per cent, iodo-iodide solution; the ulcerations should 
 be dressed with the same solution. The treatment should be con- 
 tinued even after an apparent cure has been obtained and be renewed 
 on the slightest threat of a relapse. 
 
CHAPTER XXIX. 
 INFECTIOUS DERMATOSES DUE TO PROTOZOA. 
 
 Up to a few years ago it was assumed that all infectious diseases 
 were caused by bacteria or by lower fungi closely related to the 
 Schizomycetes; those in which the organism had not been found 
 were attributed to unknown bacteria. 
 
 The discovery of the trypanosomiases, then of the parasite of 
 syphilis, the other spirochetoses, leishmanioses, etc., has opened a 
 new chapter, to which in all probability additions will be made in 
 the near future. 
 
 SYPHILIS. 
 
 Syphilis — lues venerea, pox — is a systemic infectious disease, trans- 
 missible by contact and congenital, due to the Spirochete pallida. 
 
 It is extremely contagious and consequently very widely distrib- 
 uted; it may affect all organs and all tissues without exception; 
 give rise to symptoms of the greatest gravity such as cerebral 
 syphilis, tabes, general paralysis, etc. ; and be followed by cancer of 
 the mouth, abortion and a high infantile mortality. Thus it is only 
 too true that syphilis is one of the greatest scourges of the human 
 race. 
 
 Infection usually takes place through the skin or through the 
 mucous membranes and its most characteristic manifestations are 
 exhibited on the external integument. Their description must 
 therefore necessarily figure in a text-book of dermatology. The 
 general picture of the disease will be given only in brief outline. 
 
 Etiology. — In May of 1905, T. Schaudinn and E. Hoffmann 
 reported the discovery in the contagious lesions of syphilis and in 
 the lymph glands, of a parasite which seemed to be the long-sought 
 causative agent of this disease. This has been definitely established 
 by their later studies and by innumerable control investigations. 
 The responsible organism had been seen a few years previously in 
 a chancre, by Bordet and Gengou, who were not able, however, to 
 follow it in the various syphilitic lesions. 
 
 The parasite of syphilis, now classified under the name of Sjjiru- 
 cheta pallida or Treponema pallidum is a protozoon of spirillary 
 form, whose cylindrical body, of an average length of 6 to 14 ju 
 and a width of at most 0.3yu, describes close-set narrow spirals, from 
 six to twenty in number; it terminates at both ends in an extremely 
 slender flagellum. An undulating membrane has so far not been 
 
SYPHILIS 611 
 
 demonstrated. Living specimens on ultramicroscopical examination 
 are seen to move actively for several hours. Some deviations from 
 this typical appearance have been observed, possibly corresponding 
 to developmental stages in a still unknown evolution. The trepo- 
 nema for a long time was refractory to culture in any artificial 
 culture-medium; Schereschewsky, W. H. Hoffmann, Sowade, 
 Noguchi and others succeeded in growing it in pure culture under 
 special conditions. 
 
 The agent of syphilis can be stained with less difficulty than was 
 originally believed. It is readily obtained in very thin smears of 
 serous exudate or tissue-juice, fixed by heat, washed repeatedly 
 for three or four minutes with a boiling mixture of the following 
 composition: To 9 c.c. of distilled water add 2 drops of a 1 per cent, 
 solution of potassium carbonate, and 2 drops of neutral glycerine; 
 heat to the boiling-point and add 10 drops of Giemsa's eosine-azure ; 
 the specimen must be very carefully rinsed in running water before 
 it is dried and examined. Burri's method is also very convenient: 
 the exudate is mixed on the slide with a small drop of India ink, 
 spread out in a very thin layer, allowed to dry in the air and then 
 directly examined in immersion oil ; the parasites stand out white on 
 the dark background. In the tissues the parasite is demonstrated 
 by means of the silver reduction methods devised by Levaditi. 
 
 The spirochetes are constantly present in very large numbers in 
 the chancre. They are also found in the glands and in great abund- 
 ance in mucous patches and recent papules of all kinds; they are 
 less frequent in the roseolar spots, a blister produced by the applica- 
 tion of a fly-plaster to a papule often contains many spirochetes. 
 Spirochetes have been found in the spleen (Schaudinn), in the supra- 
 renal capsules (Jacquet and Sezary), and in the meninges. Their 
 usual presence in the blood during the active stages of the disease 
 has often been demonstrated, especially indirectly; in the cerebro- 
 spinal fluid, the seminal fluid, the milk and the urine, the parasite 
 of syphilis is found only under special and exceptional conditions. 
 They are very rare in tertiary lesions, but Noguchi and several 
 investigators after him found spirochetes in the brains of patients 
 who had suffered from general paralysis. They are very abundant 
 in children and fetuses with congenital syphilis, notably in the liver, 
 the spleen, the suprarenals, the lungs, the blood, as well as in the 
 cutaneous lesions. The parasite has been successfully followed in 
 serial inoculation into monkeys and more recently also other animals. 
 
 Syphilis was for a long time considered as absolutely peculiar to 
 man; it was taught that neither race nor age nor sex confer immunity 
 against it, but that a first attack renders the patient permanently 
 immune. More recently it has been recognized, however, that the 
 immunity acquired by a first infection may not always be absolute 
 
612 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 and permanent; the possibility of reinfection lias been demonstrated 
 in some cases, not numerous but convincing. 
 
 On the other hand, two years before the discovery of the spiro- 
 chete (July 28, 1903) Roux and Metchnikoff showed that syphilis 
 is inoculable into anthropoid apes; Lesser, Xeisser and many others 
 confirmed these observations. Since that time it has been recog- 
 nized that inoculation is also successful in the lower monkeys; an 
 attempt has been made to utilize this fact for diagnostic purposes, 
 a procedure which actually possesses but small practical value. 
 More recently syphilis has been successfully inoculated into rabbits, 
 dogs, guinea-pigs and sheep. Inoculation into the rabbit's cornea 
 (Bertarelli) or on the scrotum of this animal (Parodi) has so far 
 yielded most positive results; their proportion is increased in serial 
 reinoculations and sometimes symptoms of generalization have been 
 noted. Experimental syphilis has already led to valuable scientific 
 findings and is sure to furnish a further abundant harvest. 
 
 According to the classical teachings, there are two modes of con- 
 tracting syphilis: by contagion or by heredity. 
 
 Acquired syphilis results from a venereal or accidental contact, 
 which may be direct or indirect; congenital syphilis is present at 
 the birth of the child and is derived from its parents. 
 
 Acquired Syphilis. — The course of acquired syphilis is subject to 
 certain laws. The infecting contact is followed by a latent period 
 known as the first incubation, usually lasting twenty-five days, 
 sometimes shortened to ten or fifteen days or very exeeptionally 
 prolonged to sixty and even to ninety days. Then the primary mani- 
 festation makes its appearance at the point of the inoculation itself, 
 as the syphilitic chancre with which at the end of about a week a 
 satellite bubo becomes associated, constituting the primary stage. 
 
 Next follows another latent period, the second incubation, of an 
 average duration of forty-five days, at the end of which the secondary 
 symptoms appear; these are of various forms, scattered and profuse, 
 usually showing a benign behavior and located especially on the skin 
 and the mucous membranes; as a rule they recur during several 
 months, or sometimes during two or three years or longer when the 
 disease is left to itself or is insufficiently treated. 
 
 Later on, especially after the fourth year, sometimes earlier, and 
 often at remote dates of ten, twenty or thirty years or still later, 
 the tertiary symptoms may appear. While they have less tendency 
 to diffusion than the secondary symptoms, they cause much deeper 
 damage to the tissues in which they are situated. They may affect 
 any organ, any apparatus, including the skin and the mucous 
 membranes and notably the nervous system, the last-named locali- 
 zation being especially formidable, 
 
SYPHILIS 613 
 
 The primary lesion, the chancre, is practically never absent, but 
 it may remain undetected, this being actually frequent in women. 
 The few known cases of "immediate syphilis" (d'emblee) or "decapi- 
 tated syphilis" in men are explained by very unusual conditions. 
 In the absence of early and energetic treatment, the secondary 
 manifestations are only very rarely absent. This remark does not 
 apply to the tertiary symptoms, which develop preferably in tainted, 
 intoxicated or exhausted individuals under bad hygienic conditions 
 and especially in incorrectly or insufficiently treated patients. 
 
 It is noteworthy that the secondary and tertiary periods are not 
 always distinctly separated, neither in time nor by the character 
 of the associated manifestations, but may widely encroach upon one 
 another [or overlap]. This subdivision is nevertheless justified by 
 the course of the majority of the cases and, moreover, is convenient 
 from the didactic point of view. 
 
 Syphilis may finally eventuate in remote sequelae which are not 
 influenced by antisyphilitic treatment. A. Fournier designated 
 these as parasyphilitic symptoms and interpreted them as indirect 
 consequences of syphilis. This group (general paralysis, tabes, 
 leukoplakia, aneurysms, etc.) will undoubtedly have to be rear- 
 ranged, for the presence of spirochetes in the brain of paretics shows 
 that in these cases at least, genuine syphilis is responsible [and this 
 is certainly true also for tabes and aneurysm]. 
 
 Among all the symptoms of syphilis, only the primary chancre 
 and the secondary or tertiary lesions involving the skin and the 
 mucous membranes enter into the scope of this book. These sec- 
 ondary and tertiary cutaneous or mucous manifestations are 
 generally designated under the name of syphilides. 
 
 Syphilitic Chancre. — Also known as hard chancre [ulcus durum], 
 primary lesion, initial sclerosis. The syphilitic chancre develops at 
 the point which has served as the infection-atrium of the virus. It 
 suffices that living treponemata derived from a contagious syphilitic 
 lesion be deposited upon a traumatic or pathological lesion, ulcer- 
 ation, herpetic erosion, fissure, or even a trifling excoriation, to 
 bring about the infection; it is not probable that they can pass 
 through the intact epidermis, but they may possibly pass through 
 the intact epithelium of mucous membranes. Transmission usually 
 takes place directly, through sexual intercourse, kissing, accidental 
 or occupational contact; much less commonly through the inter- 
 mediation of some contaminated object. 
 
 During the first incubation, the lesion which has served as the 
 infection-atrium has usually had ample time to disappear. The 
 parasite multiplies locally at first without producing a demon- 
 strable reaction and already begins to spread in the organism 
 through the lymphatics and the veins; indeed, an early excision 
 
fil4 
 
 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 of the incipient chancre, for the purpose of aborting the syphilis 
 is almost invariably unsuccessful. The production of immunity 
 is not immediate, however; the chancre is often auto-inoculable 
 during the first eleven days following its appearance, according to 
 Queyrat; this would serve to explain the cases of successive multiple 
 chancres. 
 
 An incipient chancre, better known through experimentation 
 on monkeys, presents the appearance of a very small slightly 
 papular red spot, or in other cases a scaly crust covering a super- 
 ficial erosion. The erosion and induration keep on progressing until 
 in a few days the primary sore (Fig. 181) has assumed the six follow- 
 ing characteristics, as clearly pointed out by A. Fournier: 
 
 Fig. 181. — Syphilitic chancre of the sheath of the penis, of five weeks' standing; 
 untreated. 
 
 (1) It is a slight erosion, generally of the size of a dime [about 
 1 cm.], not an ulceration; (2) it has a round, regular, orbicular 
 form; (3) without marked borders, that is, without prominence, 
 perpendicular depression or detachment, its surface being on the 
 same level as the surrounding tissues or sometimes slightly convex 
 or depressed; (4) of a color varying from red, flesh-color with 
 smooth, moist and glazed or finely granular surface, to a grayish 
 color with diphtheroid surface scattered with ecchymotic points and 
 sometimes covered with a thin brownish crust; (5) an indurated 
 base, which is recognized by grasping the chancre between the 
 thumb and index finger, across its diameter and slightly raising it; 
 thereby demonstrating a characteristic, circumscribed and dry 
 hardness, of very variable thickness, sometimes superficial, like 
 parchment or paper, in other cases deep, resembling pasteboard, or 
 nodular; (0) the chancre is accompanied by a satellite bubo. 
 
 This bubo, which according to Ricord's expression follows the 
 
SYPHILIS 615 
 
 chancre as the shadow follows the body, has its seat in the glands 
 corresponding to the lymphatic territory of the chancre. It con- 
 sists of a glandular constellation, namely a group of hard, ovoid, 
 movable, painless and non-inflammatory glands; one or two of 
 these glands are apt to be larger than the rest and may present a 
 very evident protuberance. The bubo appears from six to ten days 
 after the chancre and survives it as a posthumous witness for a 
 number of months. 
 
 The chancre itself heals in a fortnight to six weeks; the induration 
 as a rule persists for several months, sometimes actually increasing; 
 a cicatrix is seen in only about one-half of the cases. 
 
 Exceptionally, an erosion known as chancre redux may reappear 
 at the same point, after a very variable period. 
 
 The varieties of syphilitic chancre are innumerable; but the 
 typical form is by far the most common. 
 
 There occur dwarf lenticular chancres, or giant chancres; papular, 
 hypertrophic, or markedly ulcerative chancres, or echthymatous 
 chancres covered with a fairly thick crust. Although hard chancre 
 is, as a rule, solitary, multiple chancres to the number of two or three, 
 or more, are encountered nearly as frequently and up to fourteen 
 have been counted on the same patient; they are simultaneous or 
 successive, which may be due to a variable incubation, successive 
 contaminations, early auto-inoculations, or to a chancrous lymphan- 
 gitis which has given rise to local erosions. 
 
 Complications. — The onset of the chancre may be directly pre- 
 ceded by a herpetic eruption, a common and serious source of error; 
 this herpes runs the ordinary course, but one or several of the ero- 
 sions become indurated, thereby revealing their chancrous character. 
 The chancre is not uncommonly accompanied by a local and vo- 
 luminous first soft then hard sclerotic edema, notably of the vulva 
 or the prepuce (phimosis), which suggests its presence, although it 
 helps to conceal it; the chancrous induration can be felt with the 
 finger and confirms the diagnosis. The indurated chancre becom 3S 
 inflamed after traumatism, improper treatment or secondary 
 infection; it becomes painful, bleeds and suppurates; sometimes, 
 the bubo itself undergoes a usually sluggish purulent disinte- 
 gration. Superficial or penetrating gangrene and phagedena are 
 rare complications. Mixed chancre, propounded by Rollet (Lyon) 
 is more or less rare according to the environment and results from 
 inoculation at the same point with the Ducrey bacillus and the 
 treponema, their incubation being of very unequal length. When 
 the infections are simultaneous, a soft chancre develops, then 
 becomes indurated and opens again in case it was cicatrized; when 
 the infection is successive, a soft chancre becoming grafted on a 
 syphilitic chancre, it forms an ulcer in the preexisting induration. 
 
616 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 Localization. — Genital chancre in men is more frequently located 
 in the balanoprepntial groove and the sides of the frenum, but may 
 occur on any other point of the penis, the scrotum or the pubis. 
 Chancre of the meatus and intra-nrethral chancre, which are rare, 
 manifest themselves by a serous oozing and a circumscribed indura- 
 tion. In women, the labia majora and minora, the fourchette, the 
 <lit oris, and more rarely the meatus, are the seat of the chancre; hardly 
 ever the vagina. ( hancre of the uterine cervix would appear less rare 
 if it were more frequently looked for; it presents itself in the form 
 of a distinctly limited red or grayish erosion with a narrow red 
 margin and an induration perceptible to the touch. [In rare cases 
 it may become the site of cauliflower excrescences on the cervix.] 
 
 Extragenital chancre is localized on the head in two-thirds of the 
 eases, preferably at the mouth and especially on the lower lip; when 
 it straddles the free borders of the lip, it is crusted in its cutaneous 
 portion, erosive in its mucous portion. After chancre of the lips 
 come in order of frequency, chancre of the tongue and chancre of the 
 tonsils. The latter, which must not be confused with angina, nor 
 especially with the fusospirillary ulceration of Vincent, is unilateral, 
 erosive or ulcerative, nearly always diphtheroid, of woody hardness 
 to the touch, gives rise to only slight pain, persists during four or 
 five weeks and is associated with a usually enormous enlargement 
 of the retromaxillary glands. Chancres of the chin, the eyelids, the 
 conjunctiva, the nostrils, the gums, the scalp, etc., present no very 
 specific features; [the associated adenopathy usually creates a 
 suspicion of their nature]. 
 
 On the upper limbs, chancre affects chiefly the fingers, the cir- 
 cumference of the nails or the joints; it resembles a badly healing 
 panaritium or a proliferating wound. This localization is not uncom- 
 mon in physicians and midwives and the same is true for chancres 
 of the eye. Vaccination chancre has become extremely rare since 
 vaccination from arm to arm has been generally abandoned. 
 
 Chancre is also frequently situated on the breast, notably in 
 wet nurses. 
 
 It is fairly common at the anus in both sexes and is here apt to 
 assume the so-called book-leaf form. There is no region of the body 
 in which its occurrence has not been noted. 
 
 Extragenital chancres are usually the beginning of innocently 
 acquired infections, syphilis insontium, comprising occupational 
 syphilis, workshop epidemics (glass-blowers, for example), family 
 epidemics and so forth. 
 
 The frequency of extragenital chancres as compared to that of 
 genital chancres is in the proportion of 1 in 8 or 9. The possibility 
 of this occurrence must always be kept in mind so as to guard 
 against error, which may have very serious sequela?. 
 
SYPHILIS 617 
 
 Diagnosis. — In some cases the diagnosis of syphilitic chancre is 
 evident from the start; in others, the objective features of the lesion 
 merely justify a suspicion which requires to be confirmed; it is well 
 to remember the possibility of chancre no matter what may be the 
 patient's social standing or age or the seat of the suspicious lesion 
 (extragenital chancres) . 
 
 Even when the diagnosis is certain, it is advisable for reasons 
 readily understood, to state the truth only guardedly and with the 
 greatest circumspection to the patient. Where there is the least 
 doubt, and in fact in all cases, it is important to control the objective 
 diagnosis by what may be called the elements of the general diag- 
 nosis of syphilis and especially by laboratory investigations. It 
 would be a serious error to begin specific treatment before having 
 absolutely proved of the existence of syphilis. 
 
 The history, statements of a suspicious contact three or four 
 weeks before the appearance of the chancre and confrontation in 
 certain cases, possess only the value of highly probable arguments. 
 
 The best and most practical procedure for scientific demon- 
 stration consists in the ultra-microscopical examination of the serous 
 fluid which has been squeezed out of the chancre after superficial 
 scraping. 
 
 For this examination to be valid, the patient must not yet have 
 received specific treatment and no antiseptic or caustic application 
 of any kind must have been locally employed in the last five or six 
 days. The discovery of the characteristic spirochetes is conclusive; 
 in case of failure, the examination should be repeated after a few 
 days' interval [or should be repeated daily if necessary, the patient 
 meanwhile covering the lesion with a moist dressing of normal 
 saline solution]. 
 
 The Wassermann reaction does not become positive until about 
 the eighteenth day of the chancre. 
 
 In Chapter XV {'passim) may be found the essentials of the differ- 
 ential diagnosis of hard chancre and other analogous ulcerations. 
 Briefly stated, the lesions of the genital region which most frequently 
 lead to confusion with a primary sore are the following: 
 
 Traumatic ulcerations are of more irregular form, non-indurated, 
 without bubo. 
 
 Herpes may mask an incipient chancre and must be watched; 
 when it has been cauterized, treated with an irritative lotion, 
 for example with perchloride of mercury, or with certain powders 
 such as aristol, the herpetic erosion hardens, the glands become 
 swollen and the aspect may be to the highest degree suggestive of 
 chancre. After several days when the inflammation has subsided 
 under the influence of rest, baths and moist dressings, the artificially 
 induced difficulty will generally have disappeared; if necessary, an 
 ultramicroscopic examination can be carried out. 
 
liiS INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 Soft chancre, with its perpendicular borders and its irregular and 
 suppurating Moor, rarely causes difficulties; all doubts can be settled 
 in forty-eight hours at most, by the discovery of the I hicrey bacillus, 
 or better by auto-inoculation in the deltoid region. In case of mixed 
 chancre, this auto-inoculation would be positive and the discovery 
 of the spirochete practically impossible; under these difficult con- 
 ditions, the appearance of a positive serum reaction often becomes 
 the only practical way of settling the diagnosis. 
 
 The name of chancriform syphiloma is applied to a lesion which 
 may appear between the second and the fifth year, preferably at the 
 point where the original chancre was located, the features of which 
 it may closely reproduce; or it may be more irregular in contour and 
 deeper. In all cases, there is no bubo, the Wassermann reaction is 
 positive from the start and the antecedents are sufficient to post the 
 physician. The interest of this manifestation lies in its frequently 
 having given rise to the suspicion of a reinfection; it has been 
 thought that it might sometimes be the result of a specific rein- 
 oculation on an imperfectly immunized territory. 
 
 The treatment of syphilitic chancre must be very simple; it is 
 essential to avoid all irritation. 
 
 Early excision under certain conditions still has its adherents; it 
 will be discussed further on. 
 
 Cauterizations, applications of mercurial, calomel, iodoform, etc., 
 salves should be avoided; clean moist dressings, with glycerolated 
 starch or borated vaseline are sufficient. 
 
 Under the influence of energetic general treatment, a chancre will 
 heal in less than ten days. 
 
 Second art/ Stage. — From thirty-five to sixty days after the appear- 
 ance of the chancre, generally at the end of forty-five days, the 
 secondary symptoms develop. These are sometimes multiple, 
 profuse and stormy, such cases being described as secondary ex- 
 plosions. All possible degrees may occur between the nearly com- 
 plete absence of all manifestations and the forms described as 
 precocious malignant syphilis. 
 
 The secondary lesions may affect a large number of organs or 
 organic systems. Generalized glandular enlargement is never absent. 1 
 
 Roseola, papular eruptions, mucous patches and headache, are 
 
 1 The generalized adenopathy becomes progressively established in the course of the 
 primary stage. In case of chancre of the genital region, the inguinal bubo appears 
 from the ninth to tenth day after chancre; the cervical, supraclavicular, middle and 
 suboccipital glands become perceptible to touch by the twelfth to fifteenth day; 
 the cpitrochlear glands toward the eighteenth day. The value of the presence or 
 absence of generalized glandular enlargement for the diagnosis of syphilis is con- 
 siderable and too often overlooked; I have emphasized its importance for many years 
 in my hospital service. 
 
SYPHILIS 619 
 
 extremely common ; neuralgias, myalgias, arthralgias, deep bone-pains 
 are frequent; alopecia, iritis, albuminuria, abortion, are not rare. 
 
 The general condition is more or less disturbed; there often is an 
 anemic pallor, with rather marked leukocytosis; loss of strength, 
 anorexia, emaciation, neurasthenia, enlargement of the spleen. 
 
 In women especially, fever with an irregular course may be 
 observed; a typhoidal state ("typhose syphilitique") has even 
 been described but such cases are probably due to superadded infec- 
 tions. [In exceptional cases the temperature may reach or exceed 
 104° F. (40° C,)]. 
 
 These various secondary manifestations may becomes endlessly 
 combined, their coincidence often facilitating the diagnosis. How- 
 ever, in a fair number of cases the cutaneo-mucous eruptions or 
 secondary syphilides which are alone to be described in this book, 
 present themselves separately without other symptoms besides 
 generalized glandular swelling. 
 
 Secondary Syphilides. — Their general features are their poly- 
 morphism, their abundance, their dissemination, their insidious 
 non-inflammatory development, their painlessness and the complete 
 absence of itching. 
 
 The lesions are usually of a rounded form, sometimes arranged in 
 rings, loops or clusters (See Fig. 39 and 127) ; their color is yellowish- 
 red, like bacon, sometimes coppery, or of a so-called sombre hue. 
 A development in successive crops, a tendency to spontaneous invo- 
 lution and frequent recurrences complete their general properties. 
 
 The eruptive lesions of secondary syphilides belong to four prin- 
 cipal types: erythema (roseola); the papule; the ulceration; excep- 
 tionally, the bulla (in congenital syphilis). 
 
 These various morphological types may be seen in juxtaposition, 
 constituting polymorphous eruptions. 
 
 In a general way, however, one type almost invariably predomi- 
 nates; I have described these eruptive forms in the first part of this 
 book, to which the reader is referred; here it will suffice to retouch 
 the picture. 
 
 1. The erythematous syphilides are simple roseola, which is almost 
 regularly the first eruption; and circinate roseola, delayed, recurrent 
 and rebellious (p. 41). 
 
 2. The papular syphilides, often precocious, include, according to 
 the size of the lesions, a lenticular or common form (p. 142); a 
 miliary form which is follicular and obstinate (p. 396); a nummular 
 form (p. 144); and numerous morphological varieties: papulo- 
 squamous or psoriatiform (p. 113); papulo-crusted (p. 172); and 
 vegetative (p. 247). To the papular type should be annexed, in 
 my opinion, the palmar and plantar keratodermic syphilides (p. 216), 
 which may be precocious or delayed, but invariably rebellious. 
 
020 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 3. The ulcerative syphilides are especially serious and constitute 
 varieties which are malignant from the start (p. 286). 
 
 4. The bullous -syphilides are peculiar to precocious hereditary 
 syphilis (p. 177). 
 
 This enumeration does not exhaust the list of cutaneous mani- 
 festations of the secondary stage; there still remain to be mentioned: 
 
 .">. Pigmentary disturbances (p. 320). 
 
 6. Lesions of the adnexa, the hairs (p. 411) and nails (p. 436). 
 
 It is important to note that these various types of lesions are 
 characteristic only on the skin. On the mucous membranes and 
 even on the epidermis in macerated regions, these types lose their 
 distinctiveness and tend toward a more or less erosive and oozing, 
 hence highly contagious common form, which is currently desig- 
 nated under the name of mucous patch. 
 
 Secondary Syphilides of the Mucosa or Mucous Patches. — This is 
 the most common among secondary lesions and it may be stated 
 that few syphilitics are exempt from it. Through their contagious- 
 ness, mucous patches acquire social importance, for they are respon- 
 sible for most transmissions. 
 
 They usually appear after the first eruptive manifestation; 
 they often recur repeatedly during the first two or three years; 
 especially when provoked by local irritations — tobacco and a bad 
 condition of the teeth for buccal or pharyngeal patches; uncleanli- 
 ness for genital and anal patches. They have been noted in the 
 sixth and eighth year and are held responsible for the very rare 
 and extremely doubtful cases of syphilitic infection in the twelfth 
 and even in the eighteenth year. 
 
 Mucous patches may be situated at any point of the mouth, the 
 lips, the isthmus and the pharynx, especially on the tonsils and 
 faucial pillars, the commissure of the lips and in the vicinity of 
 carious teeth; at any point of the vulva; on the prepuce and glans, 
 around the anus, on the conjunctiva?, in the nasal fossse, in the 
 larynx; sometimes even in the axilla?, at the umbilicus, or more 
 frequently between the toes. The syphilides designated as mucous 
 patches of the skin have been previously mentioned (p. 144). 
 
 A distinction is made between several varieties of syphilides of 
 the mucous membranes, which correspond to the cutaneous syphil- 
 ides, representing a possible localization of the latter. 
 
 Erythematous syphilides, simple red spots, are seen especially on 
 the palate, on the cheeks and on the labia minora. 
 
 Opaline plaques, ordinary mucous patches, the most widely dis- 
 tributed variety, are characterized by a slight, sometimes hardly 
 papular elevation, on which the epidermis is swollen and whitish, 
 not eroded nor proliferating. They are encountered everywhere, 
 notably on the velum of the palate or at the vulva; they may 
 assume a fairly characteristic circinate arrangement, in arcades. 
 
SYPHILIS 621 
 
 The pharyngeal and buccal mucous patches are sometimes 
 diphtheroid, to such a degree that a confusion with diphtheria 
 occurred in cases reported by Fournier. It is probable that this 
 appearance is the result of a superadded infection (fuso-spirillary 
 association, etc.). 
 
 Erosive or papulo-erosive syphilides are papular syphilides whose 
 squamous epithelium has become detached; they present the appear- 
 ance of distinctly rounded red erosions; they often become, or have 
 been opaline. The papular mucous patches are known outside of 
 France as flat condylomata [condyloma latum]. 
 
 Papulo-hypertrophic and proliferative mucous patches develop 
 especially in uncleanly persons, at the vulva or in its vicinity, in 
 the genitocrural and intergluteal folds and sometimes at the buccal 
 commissures; on the tongue, notably on its posterior third, they 
 may constitute what the French call "toad's back tongue." I have 
 seen enormous patches of this kind on a wholly neglected scalp. 
 They consist of elevations the size of a pea to that of the thumb or 
 larger, sometimes nearly a centimeter thick, with a granular or 
 papillomatous surface, discharging a turbid and yellowish serous 
 fluid with a fetid odor. 
 
 Ulcerative syphilides of the mucous membranes are less common, 
 they are observed on the lips, at the commissures, the gums, the 
 pharynx and on all parts of the vulva. 
 
 Certain syphilitic lesions of the tongue known as smooth patches 
 or "mowed-lawn" patches are usually regarded as related to mucous 
 patches. These are dry, red, non-eroded patches deprived of their 
 papilla?, usually of an oval shape; they may become papular. Their 
 onset is often delayed and may even occur in the course of the 
 tertiary stage; Fournier considered them as contagious. They 
 are very slightly amenable to mercurial treatment and last several 
 weeks or even months. 
 
 Although usually painless, mucous patches may interfere with 
 movements, causing dysphagia, etc. 
 
 The diagnosis of mucous syphilides is easy when they occur in 
 the course of a long train of symptoms; inversely, it frequently 
 happens in practice that they furnish valuable information in 
 doubtful cases; but it would be venturesome to base a diagnosis 
 of syphilis exclusively upon the presence of mucous patches, even 
 when they assume an appearance which may seem to be typical. 
 
 The principal causes of error are as follows, in the mouth : aphthae 
 are entirely round, yellowish with a narrow carmine margin and very 
 painful. Herpes appears suddenly, is painful and polycyclic. The 
 bullous dermatoses, hydroa, may produce lesions almost identical with 
 mucous patches. Perleche is an opaline erosion situated exclusively 
 at the commissures of the lips, but encroaching upon the cutaneous 
 
622 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 epidermis of the vicinity; it is epidemic in schools and due to a 
 streptococcus. Glossitis areata exfoliativa is characterized by its 
 special border. Leukoplakia, buccal lichen planus and median 
 rhomboidal glossitis, etc., are dry, stationary or very persistent 
 lesions. Mercurial stomatitis is a diffuse inflammation, sometimes 
 with peridental or lingual ulcerations closely resembling mucous 
 patches; a coincidence is possible. 
 
 Sources of error in the genital region are represented by: trau- 
 matic lesions, which are irregular and ephemeral; erosive balano- 
 posthitis, which is characterized by whitish circinate forms which 
 may be removed by friction. 
 
 Soft chancre is purely ulcerative and suppurates profusely; it is 
 auto-inoculable. Proliferative herpes of the vulva, a very rare 
 disease, closely simulates the papulo-erosive syphilides. The same 
 is true for the post-erosive papular erythema of nursing infants 
 (Fig. 1). Finally, in uncleanly individuals, one may see in the 
 vicinity of the anus absolutely syphiloid patches of proliferative 
 dermatitis, which are of commonplace character (A. Fournier and 
 Brouardel). 
 
 [The demonstration of spirochete pallida on the surface of a 
 lesion of the mucosa is not always easy. When it can be made 
 with certainty the diagnosis is placed beyond a doubt.] 
 
 Tertiary Stage. — While it is possible to enumerate in a few lines 
 the principal secondary syphilitic lesions and to give an idea of the 
 course of this stage, such a sketch is altogether impracticable in 
 regard to tertiary syphilis; its domain is too extensive, its course too 
 varied and too irregular. I shall accordingly discuss only its cuta- 
 neous and mucous lesions. 
 
 Tertiary Syphilides.- — The general features distinguishing these 
 from the secondary symptoms are as follows: They are deep and 
 serious, not superficial and benign lesions, of an ulcerative or sclerotic 
 type, not undergoing absorption; limited and regional, not profuse 
 and scattered; monomorphous, often with a well-marked tendency 
 to become arranged in groups and to assume a circinate configur- 
 ation, "to become disciplined" to use an expression of Fournier's. 
 
 The circinate or rather semicircular arrangement of an eruption 
 would be incorrectly interpreted as characteristic of syphilitic 
 lesions; in the first place, its constituent eruptive lesions must be 
 taken into consideration. The following general statements can be 
 made: While rare in secondary syphilis (syphilides in arcades, 
 mucous patches in arcades), a circinate arrangement is very common 
 in the tertiary syphilides. It is encountered furthermore in some 
 cases of lupus, in some eczemas and psoriasis, in many erythemas, 
 in recurrent pemphigus, sometimes in mycosis fungoides, in lichen 
 planus, lichen scrofulosorum, parapsoriasis en plaques, etc. The 
 
SYPHILIS 623 
 
 eczematides and more particularly the cutaneous trichophytosis, 
 rather form complete circles. 
 
 The question of the contagiousness of these tertiary lesions 
 had been settled in the negative sense or very nearly so. Modern 
 methods of investigation, however, notably inoculation into mon- 
 keys, have shown that a certain number of these lesions are virulent, 
 the proportion being difficult to indicate. We do not know if the 
 spirochete, as has been supposed, exists here in a different form 
 from that which it assumes in chancre and in the secondary mani- 
 festations [but there is no necessity for this assumption; a gumma is 
 the effect of a spirochete in loco acting on a soil modified by the 
 existing disease. Spirochetes have been found in gummas though 
 in very small numbers. I am of the opinion that encysted or rest- 
 ing forms must also exist; but this lacks proof.] 
 
 The morphological aspects under which the tertiary syphilides 
 may manifest themselves have been previously described; they are 
 classified under six headings, as follows : 
 
 1. Tertiary erythemas (p. 41). 
 
 2. Tubercular syphilides, circinate or in patches (p. 253). 
 
 3. Ulcerative syphilides, of several varieties (p. 285); tuberculo- 
 ulcerative, atypical gummous, sclerogummous and phagedenic. 
 
 4. Syphilitic gummas (p. 267). 
 
 5. Tertiary vegetative syphilides (p. 247). 
 
 6. Diffuse hypertrophic syphilomas and syphilitic elephantiasis (p. 
 368). 
 
 These various lesions may occupy any region of the integument 
 or of the mucous membranes. It may serve as a useful guide, 
 however, to mention the types which occur especially in some special 
 regions. 
 
 The center of the face, the nose and the lips, is one of the elective 
 foci of tertiary syphilis in all its forms, dry tubercular, ulcerative, 
 proliferating and leontiastic. Superficial confluent tubercular syph- 
 ilides, closely analogous to rosacea, are also observed in this location. 
 
 In the mouth, on the palate and the pharynx, superficial tuber- 
 cular and ulcerat ve syphilides are met with, as well as perforating 
 gumma. 
 
 On the tongue, there occur gummas, gummous and sclero- 
 gummous infiltrations, sclerotic glossitis and sometimes tubercles. 
 
 On the scalp, gummas and tuberculo-ulcerative syphilides are 
 not uncommon; the crusted and superficial variety of the latter 
 may simulate psoriatiform eczematides. To the palmar and plantar 
 regions belong the psoriatiform so-called keratodermic syphilides. 
 On the extremities, syphilitic elephantiasis may develop. On the 
 external genital organs of both sexes, gummous infiltrations and 
 gummas are found, as well as proliferative, chancriform, phage- 
 denic syphilides, etc. 
 
624 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 For the diagnosis of each of these forms, the reader is referred to 
 the description of the eruptive lesion which distinguishes it (Part I, 
 Morphology). 
 
 Congenital Syphilis. The teachings on the subject of congenital 
 syphilis and the multiple problems involved in its investigation 
 have been greatly influenced by recent scientific acquisitions, the 
 discovery of the spirochete and the introduction of the Wassermann 
 test. Without entering into details, I shall limit myself to stating 
 the conclusions which are agreed upon or at least tend to become 
 generally accepted. 
 
 Hereditary syphilis, better named congenital, is always of maternal 
 origin; it is transmitted from the mother to the fetus by way of the 
 placenta rather than through the germ-plasm or the ovum. 
 
 As the mother of a child born with syphilis is always herself 
 syphilitic, even if she appears healthy (Wassermann reaction), this 
 fact affords a simple explanation of Colles' law (immunity of the 
 mother of a child born with syphilis) and Prof eta's law (immunity 
 of an apparently healthy child toward its syphilitic mother). So- 
 called conceptional syphilis, or through reflex ("choc en retour") 
 in utero (syphilization of the mother by a fetus conceived from a 
 syphilitic father) is an error in interpretation of the facts. A 
 syphilitic father can transmit virulent syphilis to his child only 
 through intermediate infection of the mother; but on the other 
 hand, without syphilizing the mother he can transmit to his off- 
 spring, like an alcoholic or tuberculous father, both physical and 
 psychic disturbances of development and a tendency to malfor- 
 mations; this heredo-dystrophy mayor may not be associated with 
 congenital syphilis of the child. 
 
 Congenital syphilis differs from acquired syphilis in a funda- 
 mental factor: the infection, of placental origin, takes place by the 
 hematogenous route and is visceral from the start. The primary 
 stage is accordingly absent in hereditary syphilis; there is no 
 chancre; moreover, the secondary symptoms and the visceral 
 manifestations of tertiary character are intermingled instead of 
 successive. The course is therefore much less regular. 
 
 In addition, the specific manifestations may become associated 
 with dystrophic disturbances, malformations and various patho- 
 logical tendencies, due to poisoning of the germinal tissue, sperma- 
 tozoa and ova, as well as infection of the entire maternal organism, 
 so that it is readily understood that the clinical picture of congenital 
 syphilis may be rather polymorphous. 
 
 [The offspring of a woman in the early stages of syphilis is always 
 syphilitic; in the later stages the child may or may not be syphilitic. 
 In a series of pregnancies the first products of gestation may be 
 abortions or dead children, then children born alive and syphilitic, 
 
SYPHILIS 625 
 
 then a series of apparently healthy children. Some of these appar- 
 ently healthy children will really be free from syphilis and some 
 may develop signs of syphilis within a few years; or possibly the 
 first lesion will appear only after the lapse of many years. Some- 
 times among the later children of a series, healthy and syphilitic 
 children alternate. 
 
 The explanation of these phenomena is simple but not generally 
 understood. The blood of the syphilitic mother in the first year or 
 two after infection is loaded with spirochetes some of which are 
 sure to enter the uterine arteries and infect the fetus, producing 
 there the active lesions of syphilis. In the tertiary stage of the 
 mother's syphilis the spirochetes have become fixed in her tissues 
 and her blood-stream only occasionally contains a few spirochetes. 
 Under these conditions it is a matter of chance whether or not the 
 spirochetes will reach the placenta and thus infect the fetus. But 
 the blood of the fetus shares the quality of its mother's blood; in 
 late syphilis, the fetal blood is ab ovo the blood of a tertiary syph- 
 ilitic and contains the same substances which have given to the 
 mother that kind of immunity which Neisser called anergy. It is 
 this condition which renders her immune to a fresh infection though 
 it offers no protection against local tertiary lesions. The spirochetes 
 of a tertiary syphilitic mother that happen to penetrate to the fetus 
 find conditions there like those in the mother. They produce no 
 acute syphilis but becoming localized in the tissues develop the late 
 lesions of syphilis hereditaria tarda.] 
 
 The cutaneous and mucous manifestations alone are to be con- 
 sidered in this book; the other symptoms will accordingly receive 
 merely a brief mention. 
 
 A classical distinction is made between early and delayed mani- 
 festations of congenital syphilis. 
 
 Precocious congenital syphilis sometimes manifests itself at birth 
 by a peculiar fades: the skin is lifeless, wrinkled, flaccid, withered, 
 like that of a very old man; the skull is deformed, with an abnor- 
 mally high forehead ("olympian brow"), a natiform cranium, 
 hydrocephalus, dilatation of the cranial veins and general athrepsia 
 (Fig. 182). 
 
 At birth, children with congenital syphilis may present three 
 symptoms: syphilitic pemphigus; very frequently, an irritative 
 serous, later purulent, coryza, drying in greenish crusts and inter- 
 fering with respiration and nursing; mucous patches, situated espe- 
 cially on the lips, often at the commissures, either fissured or 
 radiating, rose-colored or opaline, oozing, crusted, sometimes with 
 an indurated base and painful; they are a common cause of infec- 
 tion of wet-nurses. 
 
 Very soon, in the first weeks of life and usually before the fourth 
 40 
 
626 1SFECTI0US DERMATOSES due to protozoa 
 
 month, the cutaneous syphilides make their appearance. These 
 have been especially well studied by Jacquet. 
 
 Polymorphous erythemato-papular syphilides consist of more or 
 less rounded salmon-colored or dark-red erythematous spots, situated 
 on the buttocks, on the lower limbs, on the neck, around the mouth 
 or in the folds. Some fade and disappear while others increase in 
 size and become scaly, or thicken into papular discs; the elevation 
 is often marked at the borders (cirdnate erythemato-papular syphilide I 
 and sometimes at the center of the spots (extended papulo-lenticular 
 syphilide). A well-marked "collarette of Biett" (p. 142) may be 
 observed at their circumference. 
 
 Jacqnet has pointed out that the palmar and plantar syphilides, 
 known as syphilitic pemphigus, are of the same type and become 
 bullous only in consequence of local factors. 
 
 Fig. 182.— Early congenital syphilis; child of three months. Note the hydro- 
 cephalus, the dilatation of the cranial veins, the papulo-erosive syphilides of the 
 buttocks, loins, thighs, etc., the large abdomen and the puny limbs. 
 
 The erythemato-papular syphilides may become erosive through 
 maceration, or crusted and impetiginous, or sometimes ulcerative 
 at points exposed to pressure or irritated by fecal matter; or, rarely, 
 very scaly and psoriatiform. Furthermore, an acneiform syphilide 
 has been described, formed by small umbilicated papules, centered 
 by a small crust and agglomerated in patches. 
 
 These polymorphous erythemato-papular syphilides are often very 
 difficult to distinguish from the gluteal erythema of the newborn 
 (p. 31). They are the substitute in congenital syphilis of the 
 roseola and the various papular syphilides of adults; as a rule they 
 are associated with mucous patches and sometimes with lesions of 
 the nails and alopecia. Gummas are rare. 
 
 Proper treatment of newborn infants having congenital syphilis 
 saves the lives of the majority [without proper treatment very 
 few of them survive even a year]. These children must never be 
 entrusted to a healthy wet-nurse, but must be nursed by their own 
 mother. In order to protect their digestive functions, mercurial 
 
SYPHILIS 
 
 627 
 
 medication by the mouth with van Swieten's fluid, etc., is prefer- 
 ably replaced by mercurial inunctions (1 or 2 grams of mercurial 
 ointment daily). It is advantageous to administer injections of 
 novarsenobenzol in watery solution (5 mg. as the maximum dose 
 per kilogram of body weight per week) into a scalp vein or in oily 
 suspension into the buttock. 
 
 Fig. 183. — Congenital syphilis. Circinate tuberculo-squamous syphilide on the thigh 
 of a girl aged eleven years. 
 
 Syphilis congenita tarda is the form observed in older children, 
 in adults or even in old persons. For this chapter of pathology we 
 are almost entirely indebted to the contributions of my teacher, 
 A. Fournier, prior to whom the remote evidences of congenital 
 syphilis were generally referred to scrofulo-tuberculosis, rickets, etc. 
 It has been claimed that these patients must have had early mani- 
 festations and that it is only the diagnosis that is delayed in such 
 cases. This is probable but not certain. The didactic and practical 
 importance of the subject is nevertheless considerable. 
 
 The remote symptoms of congenital syphilis are in part specific 
 and in part dystrophic in character. 
 
628 
 
 ISEECTIOVS DERMATOSES DUE TO I'h'OTOZOA 
 
 Decidedly specific are those which plainly present the features of 
 tertiarism (Fig. 183); these require therefore no special description. 
 Aside from the external integument, they affect chiefly the velum 
 of the palate, the pharynx, the tongue, the nasal fossa? and the 
 genital organs and are as a rule essentially ulcerative and destructive. 
 
 Under the name of stigmata of congenital syphilis, a series of 
 malformations, developmental disturbances and lesions have been 
 grouped, whose characters point to syphilis in the parents on simple 
 examination of the patient. Some are of a dystrophic character, 
 while others are residues of specific lesions; efforts are now under 
 wax to separate these two groups of symptoms. 
 
 The principal signs are the following: Hutchinson's triad, namely 
 dental malformations (Fig. 184), ocular lesions and auditory dis- 
 turbances; bony deformities such as cranial and nasal malforma- 
 tions, "sabre-blade" tibia and exostoses; testicular atrophy; infan- 
 tilism; gluteal cicatrices of Parrot and radiating cicatrices of the 
 lips. 
 
 Fig. 184. — Congenital syphilis. Hutchinson's teeth 
 
 Pathological Anatomy. — Before the discovery of the spirochete, 
 the syphilitic lesions had already been recognized as possessing the 
 features of an infectious inflammation; this affects in the first place 
 the arterial and venous bloodvessels, altering the vascular walls and 
 giving rise around them to the production of cellular infiltrations 
 composed for the most part of plasmocytes. 
 
 The more or less circumscribed or diffuse newformations which 
 make up these infiltrations are capable of resolution in the primary 
 or secondary stage of the disease, in the sense that they may undergo 
 retrogression and practically complete absorption; the tertiary 
 new formations, on the contrary, are incapable of resolution and 
 tend lo form sclerotic tissue, provided they do not undergo necro- 
 biosis; this may occur early, while the pathological tissue still has 
 an embryonic structure, or later, after the sclerosis has become 
 established. 'The name of giumnous degeneration is employed to 
 designate this necrotic process in either case. 
 
SYPHILIS 629 
 
 In .syphilitic chancre, the cellular infiltration of the cutis is very 
 dense; the connective-tissue bundles are swollen, the walls of the 
 bloodvessels are greatly inflamed, the epidermis is thickened at the 
 borders, but has lost a number of its layers at the center, the remain- 
 der being infiltrated with leukocytes and fibrine as well as degener- 
 ated; in many cases, thinned and elongated interpapillary buds 
 are its only residue. The treponema flourishes, especially in the 
 vascular walls, whence they seem to emigrate in part into the 
 vascular lumen, which is very important in view of the generali- 
 zation of the infection; in part, into the connective-tissue bundles 
 and spaces, whence the lymphatics carry them into the glands; 
 and finally in the epidermis, where they may be transmitted by 
 contagion. 
 
 The lenticular papule may serve as the model of a secondary 
 syphiloma (Fig. 31). The infiltration of plasma cells interspersed 
 with a few giant cells is arranged in more or less continuous 
 perivascular cuffs. The epidermis is merely stretched; or it may 
 be parakeratotic, or edematous and infiltrated with leukocytes, or 
 degenerated, resulting in the formation of scales, crusts, erosions or 
 ulcerations. 
 
 In the roseola the cellular infiltration is very slight. It is some- 
 what more considerable in the mucous patches, which may have the 
 structure of papules, with an opaline epithelium through separation 
 of the cells and very abundant immigration of white corpuscles. 
 These lesions are literally teeming with spirochetes. 
 
 The tertiary lesions differ from the preceding in their course 
 rather than in their characters; the treponema, however, has only 
 very rarely been demonstrated. 
 
 Genuine syphilitic gumma seems to originate through thrombo- 
 phlebitis in the vascular plexus of the hypoderm; the profuse 
 cellular newformation of which it consists undergoes liquefaction 
 while at the same time the stroma becomes necrotic. 
 
 In syphilitic tubercle, the newformation, in which the bloodvessels 
 and lymphatics are greatly dilated, is partitioned by sclerotic strands. 
 As compared with the papule, it is therefore more fibrous, hence its 
 hardness; contains more venous blood, hence its dark color; and 
 the sclerosis persists after its disappearance, hence the cicatrix 
 which it leaves behind (Fig. 87). The epidermis may be hyper- 
 trophied in the proliferative varieties; or it may be edematous, 
 degenerated and infiltrated with leukocytes in the tuberculo-crusted 
 and tuberculo-ulcerative forms. The crust, which characterizes 
 the last two forms as well as the secondary ulcerative sjphilides of the 
 precocious malignant form, develops at the expense of the epidermis 
 and the infiltrated necrotic upper layer of the cutis; it accordingly 
 precedes the ulceration. Endarteritis and phlebitis are regularly 
 
030 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 found around all tertiary syphilomas. All these forms may present 
 a tuberculoid structure (Nicolas and Favre). 
 
 The lesions of congenital syphilis do not markedly differ from 
 those of acquired syphilis. The abundance of spirochetes in its early 
 manifestations has already been referred to. 
 
 Diagnosis. — The diagnosis of syphilis should always be guarded; 
 I repeat that the patient should be very cautiously informed of its 
 existence. 
 
 Sometimes the diagnosis is obvious from the start, while in other 
 cases, numerous and painstaking investigations are required. It 
 may happen that in spite of these investigations no definite con- 
 clusion is possible. Even in countries supplied with well-informed 
 physicians, a considerable number of previously undiscovered cases 
 of syphilis are met with and this number has grown since our 
 knowledge of the specific origin of the so-called parasyphilitic 
 diseases and since the common employment of the Wassermann 
 reaction. 
 
 In connection with every type of syphilitic symptoms, I have 
 indicated its diagnostic features, based on its objective character- 
 istics. Some of these are indicative, notably the typical hard 
 chancre, roseola, lenticular papular eruption, arciform syphilides, 
 alopecia areolata, pigmentary syphilide of the neck, circinate 
 tertiary syphilides, etc. 
 
 When it is not possible to affirm the existence of syphilis from 
 the morphological aspect of a given lesion, as is true in by far the 
 majority of cases, there is a series of indirect measures at our com- 
 mand that enable us to arrive at a certainty; these are of unequal 
 intrinsic value and not indiscriminately applicable in all stages of the 
 disease; nor is it always possible or necessary to employ them all. 
 
 Among these procedures, some are of a clinical nature and furnish 
 only more or less probable data. 
 
 They are based upon: (1) the presence of concomitant lesions; 
 certain associations are almost pathognomonic; I have emphasized 
 the value of progressive general glandular enlargement; (2) the 
 regular succession and sequence of the lesions; and (3) on the 
 history of exposure to contagion and the examination of the con- 
 taminating party (Bassereau). The ex-juvantibus method [test by 
 treatment] has too many serious disadvantages to justify its 
 employment. 
 
 Recent discoveries have enriched these traditional diagnostic 
 principles by the introduction of new scientific procedures belonging 
 to the domain of the laboratory. 
 
 The demonstration of the spirochete, in stained smears or by 
 direct ultra-microscopical examination of the serous discharge, 
 constitutes the method of choice in case of oozing lesions of the 
 
SYPHILIS 631 
 
 first stages, namely a chancre or mucous patches; a positive result 
 is absolute proof. However, this demonstration fails in the ulcer- 
 ative lesions, even of the secondary period; it is very complicated 
 in non-ulcerative syphilides and negative tests, even when repeated, 
 possess no value. In the case of tertiary syphilides, this method is 
 of no assistance at all. 
 
 The demonstration of the spirochetes in biopsy-sections requires 
 more time and a more elaborate technic; its value is open to the 
 same objections as those of the direct procedure. It is applicable to 
 the non-ulcerative lesions of the most virulent stage of the disease. 
 
 The method of demonstrating the virulence of a lesion by inocula- 
 tion into monkeys, as formulated by Thibierge and Ravaut, or by 
 inoculation of the rabbit's cornea or scrotum, is absolutely con- 
 clusive when the outcome is positive. But its inherent difficulties 
 and the delay prevent its employment as a customary procedure. 
 
 The sero-diagnostic method of Wassermann-Bruck-Neisser, based 
 on the complement-fixation method of Bordet-Gengou, depends, 
 not upon the demonstration of the noxious agent, but upon the 
 demonstration of the resulting humoral changes. Its technic is 
 extremely delicate; it necessitates minute precautions with con- 
 trols and a correct interpretation of the findings. 
 
 The fact is now known that the Wassermann reaction is not 
 strictly specific, for a positive reaction is yielded by yaws, trypanoso- 
 miases and leprosy. In a general way, however, under ordinary 
 conditions and with a reliable worker, a positive outcome may be 
 credited with absolute value and a series of negative results with a 
 value of great probability. 
 
 Sero-diagnosis is not applicable in the initial stage of the chancre, 
 because the reaction does not appear until about three weeks after 
 the onset of the primary lesion. It is a valuable aid in the secondary 
 stage and especially in the tertiary stage. It is well to keep in 
 mind, however, that the only information supplied is to the effect 
 that the individual is syphilitic, without justifying a statement that 
 a given doubtful lesion presented by this individual is itself of 
 syphilitic nature. The Wassermann reaction is most serviceable 
 in the latent stages of the disease, the other methods, except the 
 luetin test which will be discussed presently, being inapplicable at 
 these times. It may also be utilized to a certain extent in the 
 direction of the treatment. 
 
 Milian and others have studied under the name of reactivation 
 the reappearance of a positive Wassermann reaction under the 
 influence of treatment with arsenicals; it is claimed to occur early 
 (from the fifth to eleventh day) in the secondary stage, but is transi- 
 tory; rather delayed (toward the fifteenth day) and generally 
 prolonged in the tertiary stage. [In my opinion the "provocative" 
 
632 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 Wassermann test is not only useless but is apt to be misleading. 
 Cf. Am. Journ. Syphilis, April, 1919.] 
 
 For the cutaneous reaction to luetin, credit is due to Noguchi 
 (1912). Luetin is a sterilized emulsion of a culture of six strains of 
 Spirochete pallida; it is employed in intradermic injections. The 
 results yielded by it are not always very reliable. A positive 
 reaction manifests itself after twenty-four to forty-eight hours, by 
 the appearance of a papular or pustular elevation which lasts a week 
 or longer; sometimes it is sluggish or delayed. 
 
 A negative reaction is erythematous or faintly papular and sub- 
 sides by the fifth day. It is claimed that the percentage of positive 
 results is only 33 in the primary stage and 47 in the secondary stage, 
 but from 80 to 90 in tertiary syphilis, whether latent or congenital; 
 so that there is no conformity with the Wassermann reaction. A 
 certain number of non-syphilitic persons react likewise. An analo- 
 gous reaction to that of luetin, which is on the whole only a manifes- 
 tation of allergy has been obtained on the other hand with extracts 
 of syphilitic organs and even with other substances. The value of 
 the luetin-reaction is still a matter of controversy. [That the 
 reaction is not specific is shown by the fact that it may occur after 
 an injection of agar (Stokes) and possibly other substances; more- 
 over a reaction is regularly obtained in non-syphilitics who have 
 ingested iodides as long as a month before.] 
 
 The histological diagnosis of syphilis through examination by 
 biopsy has been relegated to a secondary rank; under certain con- 
 ditions and especially in combination with sero-diagnosis, this 
 method may prove serviceable. 
 
 It will be readily understood that the various procedures outlined 
 above may be combined in several ways according to the supposed 
 stage of the disease. 
 
 Treatment.— Syphilis is one of the diseases against which we are in 
 a good state of preparedness. 
 
 Lacking a preventive or curative serum, which remains to be dis- 
 covered, we possess mercury which often does wonders when it is 
 properly employed and well tolerated; and there are furthermore 
 the recently introduced arsenical compounds, which are still more 
 powerful; a few medicinal adjuvants and hygienic prescriptions 
 complete our therapeutic armamentarium. 
 
 Mercury. — It is not known if mercury acts directly as a parasiti- 
 cide, or through the intermediation of antibodies, or by increasing 
 the defensive reactions of the organism, etc. A few r days of treat- 
 ment suffice to render the demonstration of spirochetes in the syphi- 
 litic lesions impossible. At any rate, mercury not only cures the 
 symptoms but also prevents relapses and tertiarism and even 
 hereditary transmission. Like main' others, I have been able to 
 
SYPHILIS 633 
 
 note that the vast majority of syphilitics who were treated with 
 mercury alone for a long time and with good doses remained definitely 
 free and acquired a permanently negative sero-reaction. 
 
 The mode of introduction of the medicinal agent is not of capital 
 importance in itself, the essential factor being the amount which has 
 really been absorbed. The reason why the old mercurial fumi- 
 gations have been abandoned and the obstacle to the adoption of the 
 inhalation method, through the mercurial flannels of Merget or 
 through the powder- or ointment-bags of Welander, which the 
 patient must wear on his person night and day, consist in the 
 uncertainty as to the dosage absorbed under these methods of 
 administration. 
 
 Mercurial inunctions are open to the same criticism; furthermore, 
 they are dirty and suggestive. They enjoy great popular favor, 
 however, especially abroad; for children of tender years, they con- 
 stitute the procedure of choice. [A 30 per cent, calomel ointment 
 seems to be not less efficient, and has the avantage of cleanliness.] 
 
 The full-strength or 50 per cent, mercurial ointment is employed 
 for these inunctions, in daily doses of 6 or 7 grams for a man, 5 
 grams for a woman, 1 or 2 grams for a newborn child. The inunc- 
 tions must be applied for a long time, during ten to fifteen minutes, 
 until there is apparent penetration; the regions should be carefully 
 alternated, rubbing on the first two days one of the sides of the 
 thorax, on the following days the internal aspect of one of the limbs, 
 after which the series is resumed, avoiding the axillse, the groins 
 and the scrotum, which are too much exposed to hydrargyria. The 
 treated part is covered with gauze for the night; on the following 
 morning it is carefully cleansed with soap and dusted with powder. 
 [Since mercury is slowly vaporized at the body temperature a part 
 of the effect of inunctions is due to respiratory absorption. Inunc- 
 tions are therefore most effective when made in a small room with 
 closed windows.] 
 
 The buccal route, for a long time the most generally used, also 
 has its disadvantages: uncertainty as to the actual penetration of 
 the dose into the tissue-juices, low effectiveness and lasting digestive 
 disturbances; the latter attract little attention on acount of their 
 delayed appearance, but occur almost infallibly in patients who have 
 been treated for a long time. 
 
 Use is made either of van Swieten's fluid, 4 to 6 teaspoonfuls 
 daily in a little milk, or Dupuytren's pills (bichloride of mercury and 
 extract of opium aa 00.1, excipient and glycerine q. s. for 1 soft pill) 
 or especially Ricord's pills (protoiodide of mercury 0.05, extract of 
 opium 0.01, excipient and glycerine q. s.) to be taken at meals, in 
 a dose of 2 pills daily for an adult, 1| for a woman. 
 
 The rectal route may be utilized. Audry recommended supposi- 
 
634 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 tories of cacao butter with an addition of 40 per cent, gray oil, in 
 such a proportion as to contain 0.02 to 0.04 of metallic mercury; 
 this method is slow in its action. 
 
 Mercurial injections are at present one of the fundamental methods 
 of treatment of syphilis. They insure a strict dosage, exclude fraud 
 or negligence on the part of the patient, spare the digestive apparatus 
 and when properly applied and well tolerated are found to be almost 
 as rapidly effective as arsenical medication. At the present writing, 
 I regard mercurial injections as an indispensable complement of 
 treatment with the arsenobenzols. Further on I shall point out 
 how the two medications may be combined. 
 
 Mercurial injections are made in the region of the buttocks. 
 The pain of the puncture is practically zero, abscesses are no longer 
 to be feared, pain coming on after the injection is insignificant 
 provided the technic is correct and nodosities are rare and usually 
 painless. On the whole, the drawbacks of the method cannot be 
 compared with its advantages. 
 
 The technic is now definitely established and the following rules 
 must be observed: The necessary implements are a needle from 
 6 to 7 cm. long, preferably of iridium-platinum and an accurately 
 divided sterilizable syringe made entirely of glass; the whole outfit 
 is first to be boiled. The puncture-points are selected as follows: 
 (1) On a horizontal line passing three or four fingers' width below 
 the iliac crest; (2) on a vertical line passing two fingers' width from 
 the intergluteal fold. It is advisable to begin with the left buttock 
 and to inject on the two sides alternately, of course avoiding the 
 previously punctured points. The patient lies on the abdomen, with 
 complete muscular relaxation; the area selected is cleaned with a 
 cotton wipe soaked in benzine, ether or alcohol. The needle is 
 plunged in vertically with a clean thrust and a minute is allowed to 
 pass, in order to be sure that no drop of blood flows through its 
 lumen; should this happen, the needle will have to be [partlyl 
 withdrawn and inserted elsewhere, to guard against embolism; 
 otherwise, the syringe containing the desired dose is adjusted [and 
 the fluid slowly injected]; at the end of the procedure, a drop of 
 collodion or a piece of plaster is placed over the puncture-orifice. 
 
 Mercurial injections are administered with insoluble compounds 
 or with soluble salts. 
 
 The former have the advantage of being applicable at longer 
 intervals, usually once a week. The soluble injections must be 
 repeated every day, causing a loss of time and much inconvenience 
 outside of hospital practice; they have a powerful and rapid, but 
 less durable effect. 
 
 Gray oil is the most practical insoluble injection. The formula 
 of the Codex for 1908 contains: purified mercury, 40 grams; lano- 
 
SYPHILIS 635 
 
 line, 26 grams; vaseline oil, 60 grams; 1 c.c. contains 0.4 gm. of 
 mercury. This preparation is employed luke-warm, using a syringe 
 of narrow caliber [tuberculin syringe]; 0.07 to 0.12 Hg weekly 
 should be injected into a man and 0.06 to 0.10 into a woman. 
 
 Calomel injections are much more energetic and efficient; their 
 action is nearly as rapid as that of arsenobenzol. They are often 
 alone sufficient to cure certain lesions, such as the obstinate palmar 
 syphilides and the tertiary lesions of the tongue. The dose to be 
 injected is from 0.05 to 0.10 (or 1 c.c. of the formula: calomel (by 
 vaporization) 0.5 or 1.0, vaselin and vaselin oil, aa 5 grams). 
 Their drawback consists in the sometimes severe but as a rule quite 
 tolerable pain caused by them. This is largely obviated, as I have 
 suggested, by adding per 1 c.c, 0.03 of guaiacol and 0.02 of cam- 
 phor. The same addition is advantageously made to gray oil and 
 to the other insoluble injections. 
 
 The basic salicylate of mercury (0.10 per injection), or yellow 
 oxide (0.05 to 0.10) may be substituted for gray oil, without, how- 
 ever, being preferable to it. 
 
 [With all the mercurial suspensions in oil, it would seem physio- 
 logically preferable to use olein (ol. olivarum) rather than foreign 
 bodies like the paraffins (vaseline, vaseline oil, etc.). Furthermore, 
 the larger the volume of the injected mass the greater the pain. I 
 employ calomel in 20 per cent, suspension and the salicylate in 33 
 per cent, suspension, injecting a proportionately smaller amount 
 of fluid.] 
 
 Soluble injections are made with benzoate of mercury according 
 to the formula of Gaucher; with bibromide or biniodide of mercury, 
 or with the cyanide. The daily dose is from 0.01 to 0.03 of each of 
 these salts; the pain is generally moderate. Bichloride of mercury 
 is more painful and should be rejected for this reason. Tolerance 
 varies greatly according to the patients and it is advisable to look 
 in each particular case for the most readily tolerated formula. 
 Various preparations of mercury disguised under proprietary names 
 (hermophenyl, enesol, etc.), are not sufficiently reliable in their 
 action. 
 
 Intravenous injections of soluble salts may also be recommended ; 
 the cyanide of mercury alone is used for the same [the bichloride 
 is also employed]. They are entirely painless and very promptly 
 efficient. [They are administered in normal saline solution.] 
 
 Local mercurial treatment of syphilides, especially the tertiary 
 manifestations, is entirely reasonable; it serves as an adjuvant of the 
 general medicinal treatment and prior to the era of arsenobenzol 
 injections was recommended by me in those cases where the patient's 
 buccal or intestinal condition prevented an energetic general mer- 
 curialization. I have been well pleased, especially in the treatment of 
 
636 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 circumscribed leukoplakias and leukoplasic ulcer, with local injec- 
 tions of a few drops of an isotonic cyanide solution of 1 to 3000 
 (formula: cyanide of mercury, 0.3.'!; cocain chlorhydrate, .">.(); 
 sodium chloride, 7.0; sterilized water, 1 liter) repeated twice weekly. 
 The traditional mercurial plaster, salves and mercurial baths are no 
 longer indicated at the present time. 
 
 Mercurial complications, hydrargyria are possible with all com- 
 pounds, all formulas and all methods without exception. Their 
 possible occurrence renders it necessary first to test the patient's 
 sensibility and always to proceed with caution. 
 
 Mercurial stomatitis was a distressing and formidable symptom 
 in the days when salivation was systematically aimed at. The 
 present tendency is to consider it as due to the fuso-spirillary asso- 
 ciation and induced by the irritation of the mouth. Its development 
 may be prevented by putting the mouth in good condition before 
 beginning the treatment and by maintaining great cleanliness. 
 The use of tobacco must be interdicted. The gastro-intestinal 
 apparatus likewise requires continuous supervision. Finally, the 
 urine must be watched. 
 
 Arsenic. — Arsenic in all its forms had long been advocated as an 
 adjuvant of mercurial treatment; sodium arsenate, the cacodylates, 
 methylarsenate, hectargyrium and other preparations have served 
 for this purpose. 
 
 Since a dozen years, however, a direct specific medication has been 
 sought in new arsenical compounds. Atoxyl and arsacetine were 
 promptly abandoned as too dangerous. The " hectine" of Mouneyrat 
 has enjoyed a certain popularity, but this product does not seem 
 to me to be better than a good adjuvant. 
 
 In the course of his investigations on the arsenic treatment of the 
 spirilloses, Ehrlich in 1909 stopped at a compound, the dichlor- 
 hydrate of dioxydiamido-arsenobenzol, w r hich was numbered 606; 
 this product was labelled with the name of salvarsan; at the present 
 writing it is manufactured everywhere and known as arsenobenzol. 
 [In the United States the official name since 1917 is arsphenamine.) 
 Shortly afterward he recommended a related product, much more 
 convenient to employ, the dioxydiamido-arsenobenzol-monomethy- 
 lene-sulfoxylate of sodium, or 914, or neosalvarsan, which is cus- 
 tomarily designated by the name of novarsenobenzol for neo- 
 arsphenamine]. Other more or less analogous arsenical salts, notably 
 galyl, luargol, etc., have been produced and tried in France; these 
 investigations are still under way. 
 
 Briefly, arsenobenzol and novarsenobenzol constitute the anti- 
 syphilitic arsenical medication of the present day. 1 
 
 1 Wherever treatment with arsenobenzol, or the arsenobenzols, has been referred 
 to in the course of this hook, I have meant intravenous injections with arsenobenzol 
 or witli novarsenobenzol [arsphenamine or neo-arsphenamine]. 
 
SYPHILIS 637 
 
 The hope which had been aroused of a "therapia sterilisans 
 magna," a radical and rapid cure of syphilis has not been realized; 
 it must be abandoned and doses employed which do not expose to 
 the gravest risks. Nevertheless, the efficacy of arsenobenzol and 
 almost to the same degree of novarsenobenzol is not less remarkable; 
 in a few days they will cicatrize a chancre, obliterate roseola or 
 mucous patches; when employed in the primary stage and especially 
 in combination with mercurial injections, they almost certainly 
 protect against all secondary manifestations and usually maintain a 
 permanently negative Wassermann reaction. The test of time is 
 not yet sufficient to state that patients treated in this way will 
 remain free from tertiary and parasyphilitic lesions. While this 
 may be hoped for, it is advisable to complete the treatment with 
 mercury for the present. At any rate, the dangers of contagion are 
 immeasurably diminished in these "silenced" cases of syphilis and it 
 is needless to dwell upon the social importance of this result. 
 
 The manipulation of the new arsenical compounds is difficult; 
 their employment cannot be said to be absolutely devoid of danger; 
 especially in the early days, serious and even fatal results have been 
 noted. Better regulated doses and extreme precautions, however, 
 have reduced the risks of this treatment to a minimum. 
 
 There is a practically general agreement as to their administra- 
 tion only by the venous route. Those who have witnessed the intol- 
 erable pains and fearful sloughs which were often produced by 
 intramuscular injections of 606, such as were originally administered, 
 have abandoned them altogether. Balzer and Dumouthiers advo- 
 cated intramuscular injections of novarsenobenzol in doses of 
 0.25, twice daily. These are often not particularly painful, have a 
 slower action and are only rarely indicated. Nowadays, every 
 physician should be familiar with the technique of intravenous 
 injections. 
 
 Arsenobenzol is the most active and the most permanently steriliz- 
 ing antisyphilitic remedy known. Its watery solution is acid and 
 must be neutralized or rendered slightly alkaline by the addition of 
 a sodic hydrate solution, then diluted with physiological salt solu- 
 tion of 7 per 1000, prepared with pure sodium chloride dissolved in 
 freshly distilled water; the total amount to be injected is according 
 to some writers from 150 to 200 c.c, according to others 50 c.c. for 
 each 0.10 of the remedy. 
 
 Nov-arsenobenzol is generally preferred on account of the relatively 
 simple instrumentation and mode of preparation of the solution, 
 especially when the very convenient procedure of intravenous injec- 
 tions in concentrated solution of Ravaut is adopted and carried out 
 as follows: Immediately before it is to be used the contents of a 
 nov-arsenobenzol ampoule is dissolved in 5 to 10 c.c. of physiological 
 
38 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 salt solution, 4 per 1000, or the same quantity of distilled water or 
 even freshly boiled and cooled water may be employed. Solution 
 is instantaneous; the solution is drawn into an all-glass sterilized 
 syringe, provided with a short-bevelled platinum needle; the patient 
 lies down and the arm is put on the stretch ; the needle is now inserted 
 into a vein at the bend of the elbow which has been made prominent 
 by applying a rubber band on the arm; when the blood flows back 
 into the syringe indicating that the needle is properly inserted, the 
 band is removed from the arm and the piston is gently pushed in; 
 after the injection has been made and the needle is withdrawn, no 
 dressing is required. [The field of operation must, of course, have 
 been sterilized with alcohol or a weak solution of iodine.] 
 
 Some precautions are needed with all arsenical compounds. In 
 case of virulent syphilis, with multiple manifestations, it is advisable 
 to treat the patient for two or three days before the arsenical injec- 
 tion, with injections of a soluble mercury salt; this guards against 
 an attack of fever with malaise, known under the name of Herx- 
 heimer's reaction and attributed to the sudden absorption of the 
 products resulting from a large number of disintegrated spirochetes. 
 The patient must fast three hours before and five hours after the 
 injection. Examination of the urine just before the injection is 
 indispensable, so as to permit a diminution of the dose or its post- 
 ponement to a later date, in case albumin is present. The ampoule 
 must be carefully examined to see that its contents consist of a 
 light yellow powder, unaltered by penetration of air. 
 
 As a rule no reaction of any kind follows. It is advisable, however, 
 to warn the patient of the possible onset of certain symptoms, such 
 as headache, mild diarrhea, a chill with a slight ephemeral fever, 
 general prostration, nausea, sometimes vomiting, rarely an erythe- 
 matous eruption; he will be so much the more pleased should these 
 symptoms fail to make their appearance. 
 
 Threatening, grave and even fatal complications, the mechanism 
 of which has been extensively discussed, have been observed espe- 
 cially with arsenobenzol, more particularly at the time of the first 
 ventures; they have become extremely rare since the doses are more 
 carefully regulated [the quality of the arsphenamine improved and 
 more attention paid to the preparation of the patient]. A purplish 
 swelling of the face, in the course of an over-rapid injection, known 
 as "nitritoid crisis," may be efficiently controlled, as shown by 
 Milian, through injections of | mg. of adrenalin, which exerts a 
 a preventive effect. In case the injection be followed in the next 
 few hours or the first days by convulsions or delirium or spasms 
 with a tendency to coma, a profuse venesection should at once be 
 preformed, adrenalin should be injected, a spinal puncture made 
 and intravenous irrigations with physiological salt solution be 
 
SYPHILIS 639 
 
 administered. The employment of these measures has proved suc- 
 cessful in very alarming cases, which, let me repeat, are of altogether 
 exceptional occurrence. 
 
 Auxiliary Medication. — Potassium iodide, introduced into the 
 treatment of syphilis by Wallace and by Ricord, for a long time 
 advocated as a specific in tertiary lesions, has lost much of the favor 
 it formerly enjoyed, especially since the introduction of arseno- 
 benzol and since it has been shown to have no influence on the 
 Wassermann reaction. It may be described as not indispensable. 
 In the secondary stage, in daily doses of 1 to 3 grams, it serves to 
 control the headache and the painful manifestations. In the ter- 
 tiary stage, it is used, combined with mercury in doses of 4 to 12 
 grams, to stimulate the healing of sluggish lesions and against the 
 lesions of the nervous system or the viscera. Its employment should 
 be avoided, however, in the treatment of so-called parasyphilitic 
 disorders (general paralysis, tabes, etc.) and in the case of laryngeal 
 symptoms. In subcutaneous injections it is too painful, but it may 
 be administered in enemas [and has been given intravenously; but 
 this seems to me a futile procedure]. Other iodide compounds 
 besides potassium iodide are of less efficiency. 
 
 Some authors prescribe as a routine procedure a mixed iodo- 
 mercurial syrup, of the type of Gibert's syrup; it is better to admin- 
 ister the two medicinal agents separately, Sulphur medication, 
 cod-liver oil, rarely iron, more frequently hydrotherapy, cures at 
 watering-places with warm mineral springs, such as Luchon, Uriage, 
 la Bourboule, Amelie-les-Bains [or Hot Springs], or sodium chloride 
 springs, may prove of the greatest value for the improvement of 
 the patient's general condition or his tolerance of mercurialization. 
 
 It is always necessary to watch the alimentary, physical, occupa- 
 tional and emotional hygiene of syphilitic patients, cutting out 
 especially the abuse of alcohol, venereal excesses, late hours, and 
 overstrain of all kinds. A moderate use of tobacco may be permitted, 
 except at times where the production of buccal mucous patches is 
 threatened or when it seems to favor the onset of mercurial stomatitis. 
 
 General Conduct of the Treatment. — The so-called abortive treat- 
 ment of MetchnikofT consists of rubbing without delay a calomel 
 salve, 1 to 3, into the mucous membrane or an erosion which has 
 been exposed to syphilitic contact. Although it has been experi- 
 mentally tested in monkeys, this procedure is not free from dis- 
 advantages and has not been demonstrated to be superior to simple 
 washing with soap and water. [Prophylactic treatment after 
 venereal exposure is obligatory in the United States army. An 
 experience based on several hundred thousand cases shows that the 
 MetchnikofT inunctions applied within six hours after exposure are 
 a practically certain preventive of infection.] 
 
640 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 Early excision of the chancre is certainly not capable, as had been 
 believed, of bringing about an eradication of syphilis; when the 
 operation is possible without producing deformities, some authors 
 have found it useful, but there is nothing to show that it modifies 
 the gravity of the infection. 
 
 A fundamental rule, which must never be slighted, is as follows: 
 Never begin specific treatment before the diagnosis has been positively 
 established: this would be a serious error, which before long would 
 inevitably lead to insuperable difficulties. 
 
 When the diagnosis is definitely established, the general specific 
 treatment must at once be instituted, taking care at the same time 
 of the local lesions and guarding against contagion. Recent experi- 
 ence has shown the great importance of a vigorous offensive, striking 
 hard and strong, at least in the primary stage. In all stages of the 
 disease, we must aim not only at extinguishing the actual manifes- 
 tations, at "bleaching the syphilitic" to use a French expression, 
 but at completely stamping out the virulence of the disease and 
 safeguarding the future — aims which are usually attainable. 
 
 The problems dealing with the general conduct of the treatment 
 have been reawakened by the introduction of the arsenical medica- 
 tion. The era of trials and discussions is not yet past, so that no 
 detailed and definite rules can be formulated. 1 shall therefore 
 restrict myself to describing my actual mode of procedure and that 
 of the majority of experienced syphilographers. 
 
 It is quite generally agreed to begin in all cases with a medication 
 which although cautious must be as energetic as the patient can 
 tolerate; and to continue with the tried and approved method of 
 chronic intermittent treatment. 
 
 It seems to me highly advantageous to begin the treatment with 
 novarsenobenzol or arsenobenzol. These remedies are positively 
 indicated for patients likely to contaminate their environment, 
 married persons, those expecting to be married, fathers of families, 
 prostitutes, etc. ; or in the presence of malignant symptoms or lesions 
 of a destructive character; or when a bad condition of the teeth, 
 which is common, or of the intestinal tract suggests that mercury 
 will be badly tolerated; or in tuberculous patients in whom the 
 breaking down of tubercles is favored by mercury. Inversely, these 
 remedies should be omitted or very cautiously employed in cases 
 of cerebrospinal, meningeal, renal, cardiovascular or hemorrhagic 
 manifestations; under these conditions, it is preferable to rely exclu- 
 sively upon soluble mercurial injections. 
 
 In a general way, in the absence of contra-indications, I consider 
 it advisable to give at first about 5 or 6 injections of novarseno- 
 benzol at a week's interval (not less than four and very exception- 
 ally more than seven) in progressive doses (of 0.30; 0.45; 0.60; 
 
SYPHILIS 641 
 
 0.75; 0.90); in case of arsenobenzol the doses are one-third smaller 
 and it is better not to go above 0.50. In this increasing dosage, it 
 is of course necessary to take into consideration the signs of possible 
 intolerance, the strength of the patient, the character and more or 
 less obstinate behavior of the symptoms. 
 
 Next, after a few weeks of rest, mercurial treatment is begun with 
 soluble injections in a series of 20 to 30 every two or three months; 
 or, as seems preferable to me, with injections of gray oil, in strong 
 doses, in series of 6 ; three of these series in the course of each of the 
 first two years, another two or three series in the course of the third 
 and again in the fourth year, appear to be a treatment capable of 
 providing adequate security. 
 
 The question has been raised why the two powerful antisyphilitic 
 agents in our possession, arsenic and mercury, should not be simul- 
 taneously employed from the start. As a matter of fact, this com- 
 bined treatment — which consists in applying during the first series 
 of novarsenobenzol injections, 4 or 5 soluble mercurial injections 
 in the intervening days — is, as a rule, very readily tolerated by robust 
 individuals, in spite of the theoretical fears which have been enter- 
 tained; stomatitis and albuminuria are of rare occurrence. 
 
 It is assuredly rational and advantageous, especially in the pres- 
 ence of some special indication (positive Wassermann reaction) to 
 interpolate in the course of the second to fourth year, one or 
 two series of novarsenobenzol injections between the mercurial 
 treatments. 
 
 The same procedure, combined or alternating medication, may 
 be adopted in the treatment of late secondary lesions or tertiary 
 manifestations. 
 
 One of the most mooted questions is that of the part played by 
 the Wassermann reaction in the conduct of the treatment. Some 
 allow themselves to be guided to a large extent by the modifications 
 of the Wassermann reaction of the bloodserum, periodically tested 
 every three months for instance. Some even go so far as to follow 
 systematically the indications furnished by the reaction of the cere- 
 brospinal fluid. Others go too far in the opposite direction and dis- 
 claim all indicative value of these reactions for the treatment. In 
 my opinion, this factor should be kept in mind, but to be guided 
 by the serum-reaction alone would result either in abbreviated 
 treatments when it remains negative, or to unduly prolonged or 
 dangerously increased medications in case it remains positive. It 
 is a matter of judgment and clinical sense. 
 
 From a very elaborate review of this question, Hudelo, writing in 
 
 Paris Medical, May 5, 1917, concludes that the following procedure 
 
 is to be recommended : At the beginning, administer 8 or 9 injections 
 
 of nov-arsenobenzol at five-day intervals until a total of 4 to 5 grams 
 
 41 
 
642 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 has been given, interpolating twenty injections of 0.01 of a soluble 
 mercury salt. After six weeks to two months, if the Wassermanu 
 test of the blood is negative, injections of soluble mercury salts are 
 to be given for six months, 10 each month, or 20 every two months; 
 if, on the contrary, the Wassermann reaction again becomes positive, 
 repeat the combined treatment of the first forty days. At the end 
 of the first period of six months, a spinal puncture is made; if it 
 reveals an abnormal condition (hypertension, albuminosis, lympho- 
 cytosis, positive Wassermann), the duration of the intervals of rest 
 must be reduced or a prolonged combined treatment be resumed; 
 when clinical symptoms are present (headache, etc.), the doses 
 should be diminished, but the series be prolonged, as recommended 
 by Ravaut. At the end of the sixth month, administer a series of 20 
 soluble mercury injections, or of 6 injections of gray oil, every three 
 months until the completion of the second year; every four months 
 during the third; every six months in the fourth and in the fifth 
 year. The Wassermann reaction should be verified about once in 
 four months. 
 
 In all probability, the new methods of specific treatment will 
 permit an abbreviation of the time-honored delay of four or five 
 years expected from syphilitics who are contemplating marriage. 
 It is advisable, however, while taking into consideration the thor- 
 oughness of the treatment and the serum-reaction, not to depart 
 too far from the limits established by long experience; as heretofore, 
 the recommendation of a course of treatment with gray oil shortly 
 before marriage is sound advice. 
 
 [As the author has well said, the period of trials and discussions has not 
 yet passed. I need make no apology for entertaining very different views 
 in regard to the administration of arsphenamine and I have little hesitation 
 in presenting them even at the risk of some repetition because it is desirable 
 that the reader become acquainted with other views. The final verdict on 
 this subject belongs to the future. 
 
 Principles of Treatment. — The fact is indisputable that many cases of 
 syphilis have been cured by a single course of injections of arsphenamine 
 or even by a single injection in the first weeks after infection. In the later 
 stages it requires prolonged treatment with many courses to bring about 
 a permanent Wassermann reaction. This difference probably depends 
 on two factors: the spirochetes have become localized in regions where 
 thejr are not readily reached by the arsphenamine or they have assumed a 
 form in which they are resistant to the drug, an encysted or spore form. 
 
 To meet the indications arising from the possibility of resistant forms we 
 employ the interrupted method of sterilization, the method which long 
 experience has shown to be the best with mercury as the laboratory has 
 shown it to be the best and, depending on the medium, often the only pos- 
 sible method of sterilization. Periods of treatment must alternate with 
 periods of rest during which the organisms may emerge from their resistant 
 stage in order that our sterilizing agents may again successfully attack them 
 in their developed form. 
 
SYPHILIS 643 
 
 To meet the indications derived from the possibility of remote or inacces- 
 sible localization of spirochetes it is necessary to employ the drug in such 
 dosage and to maintain the saturation of the blood with it for such periods 
 that even the tissues least well supplied with a circulating fluid will receive 
 an adequate amount of arsphenamine to kill the germs. 
 
 We employ the soluble salts of mercury in daily doses because we aim 
 at maintaining a fairly constant amount of mercury in the system during 
 the period of treatment. We give the insoluble compounds of mercury in 
 weekly doses because with their slower elimination we accomplish the 
 same result with less frequent injections. In rapidity of elimination, 
 arsphenamine is comparable to the soluble salts of mercury. At the end 
 of twenty-four hours only a small fraction of the quantity injected remains 
 in the system. To maintain a saturation of the system for a considerable 
 period it would be necessary to administer arsphenamine in daily doses. 
 This result, however, would not be advantageous even if it were technically 
 feasible because arsphenamine, so far as we know, acts simply as a spiro- 
 cheticide and a single injection of the drug kills all the spirochetes which 
 it can reach in adequate dosage. There are no spirochetes left in the blood 
 to be acted on by the arsphenamine administered within the next day or 
 two; it is only after the lapse of a longer time that we can again expect to 
 find free spirochetes in the blood. But the repetition of the dose at short 
 intervals for a few days serves to maintain a degree of saturation of the 
 system with the drug which makes it possible for the arsphenamine-laden 
 fluids to reach remote and outlying regions in sufficient dosage. 
 
 The principles on which my arsphenamine treatment of syphilis are 
 based are therefore : 
 
 1. The principles of interrupted sterilization to destroy the resistant 
 forms. 
 
 2. The principle of prolonged saturation to reach and destroy the remote 
 or deeply hidden germs. 
 
 Arsphenamine is now made in many chemical factories in different 
 countries. The different products are by no means equally free from 
 impurities which cause immediate or later reactions. Some of these products 
 are followed by dangerous reactions in a large percentage of cases; some are 
 far more free from these dangers even than was the original 606. The general 
 practitioner must choose his arsphenamine in accordance with the experience 
 of those specialists who have larger opportunities for acquaintance with 
 the different brands. The question of cost or of convenience in preparation 
 should have no weight in dealing with so potent a drug and so grave a 
 
 Dosage, Preparation of Solution and of Patient. The dose should be 
 proportioned to the weight of the patient, making some allowance for sex 
 and a physical condition possibly weakened by disease, alcoholism, etc. 
 A dose equal to 0.1 for each twenty-five pounds of body weight is the dose 
 for a man; 0.1 to thirty pounds of weight for a woman or a child; and half 
 that amount for an infant. With an otherwise healthy patient the first 
 dose should not be less than the full dose. The employment of a small 
 initial dose followed once a week by slightly larger doses is open to the grave 
 objection that such a procedure is likely to encourage the development of 
 arsenic-resistant spirochetes. The rise in temperature that usually follows 
 the first injection in florid syphilis is of no serious consequence. 
 
 For the preparation of the solution it is not necessary to employ a normal 
 salt solution. Freshly distilled and sterilized water in the proportion of 
 20 c.c. of water for each 0.1 of arsphenamine is a convenient solution. 
 Higher concentrations, 15 c.c. or 10 c.c. of water to each 0.1 of drug may be 
 
044 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 used it' the needle be of very small caliber so that the rate of flow is lessened; 
 but there is no advantage in this arrangement. The drug must be com- 
 pletely dissolved before the alkali is added and the alkalinization should 
 be made rapidly and exactly. For each 0.11 of arsphenamine a little less 
 than 1 c.c. of a lo per cent, sodic hydrate should be added in a stream and 
 the remaining few drops necessary for clearing the solution added slowly 
 so that the solution is decidedly alkaline but without needless excess of 
 alkali. The solution is filtered through sterile cotton or gauze into the 
 burette or irrigator which is to be suspended or held about three feet above 
 the point on the patient's arm selected for the injection. The rate of flow 
 is an important factor in the production of nervous and vascular reactions; 
 the needle should not be larger than 20 gauge; the rate of flow should not 
 greatly exceed 0.1 of arsphenamine per minute; the injection of a full dose 
 should require about five minutes. 
 
 An examination of the patient's renal function should always precede an 
 injection of arsphenamine. In the presence of a marked nephritis, the dose 
 of arsphenamine must be reduced to one-quarter or one-sixth the normal 
 dose and the effect on the kidneys watched. It is possible that the nephritis 
 is syphilitic and that its symptoms will improve after the arsphenamine. 
 In general, arsphenamine does very little harm to the kidneys, certainly 
 less than a prolonged course of mercury. It is common to find a trace of 
 albumin and a number of renal casts in the urine the day following an 
 injection. I pay no attention to a good trace of albumin or a moderate 
 number of hyaline casts and even a few granular casts. But a considerable 
 amount of albumin and many granular casts, more than eight or ten to the 
 slide, or epithelial casts may be a contra-indication to immediate further 
 treatment. These cases require judgment and careful consideration. 
 
 The night before beginning the course of treatment the patient should 
 receive a saline purge. If the treatment is to be administered in the morning 
 at about ten o'clock, he is permitted to take nothing more than a cup of tea 
 or coffee for breakfast before eight o'clock; after the injection he fasts for 
 six or eight hours and may then partake of a moderate dinner avoiding 
 heavy and indigestible food. If the injection is to be administered at two 
 or three in the afternoon the patient may eat his customary breakfast, 
 but should restrict his luncheon to a single cup of tea or clear broth with a 
 small piece of dry toast, not later than twelve o'clock; he fasts for six or 
 eight hours after theinjection and may partake of a light meal before retiring. 
 
 A course of arsphenamine consists of an intravenous injection of a full 
 dose of arsphenamine on each of three successive days. (A course of com- 
 bined treatment consists of a course of arsphenamine followed by a four 
 to six weeks' course of mercurial injections.) The reactions following this 
 energetic treatment with arsphenamine are not greater than those that 
 occur after a single injection. In fact, it is only the first of the three injec- 
 tions that causes whatever reaction may occur. If the first injection is 
 followed by a severe reaction, nitritoid or toxidermic, it would be folly to 
 give another the next day ; but these severe reactions are becoming less and 
 less frequent. It is my growing belief that most of the severe reactions, 
 assuming a reliable arsphenamine, are due to faulty technique: improper 
 preparation of the patient, inadequate alkalinization of the solution, its 
 too great concentration or too rapid administration. 
 
 After an experience of nearly five years with this method I can state 
 first, that it is as safe as any other method of employing arsphenamine; and 
 second, that its results are greatly superior to those obtained by other 
 met hods of nsiiiji' that remedy. In these statements I have the endorse- 
 ment of numerous colleagues who have had experience with this method. 
 
SYPHILIS 645 
 
 Four courses of the combined treatment should be given during the first 
 year after infection, irrespective of the Wassermann reaction. The intervals 
 of rest between the courses last six weeks between the first and second and 
 eight weeks between the others. If the patient came under treatment 
 before the appearance of secondary lesions, the Wassermann reaction will 
 probably have remained negative throughout the year and it may be left 
 to the judgment of the physician whether or not the treatment be continued 
 or the patient simply kept under observation during the next two or three 
 years with Wassermann tests every three to six months. It is of course 
 safer even though it may be unnecessary to continue treatment during the 
 second year with three courses of combined treatment and perhaps two 
 during the third year. In the present state of our knowledge it is impossible 
 to say; there is no absolute criterion of cure except a re-infection. But 
 when the patient has remained Wassermann-negative for a year without 
 treatment and a spinal puncture shows no involvement of the central 
 nervous system, he may be discharged as probably cured. But even then 
 he should be examined serologically at six months' intervals for several 
 years. Consent to marriage, however, may be given. 
 
 The syphilitic who comes for treatment in the later stages of his disease 
 should receive three courses of combined treatment each year for three 
 years. Cutaneous manifestations will heal in a few weeks at most under 
 this treatment but visceral lesions do not respond so favorably, especially 
 those of the heart and aorta and the central nervous system. Many of 
 these cases do not become permanently Wassermann-negative. They are 
 nevertheless greatly benefited by treatment and in view of the greatly 
 increased sensitiveness of the present-day Wassermann test it is an open 
 question whether or not much importance should be attached to the per- 
 sistence of a positive Wassermann reaction in old well treated cases. It is 
 not possible at present to lay down any general rules. Every case of per- 
 sistent Wassermann-positive should be examined by spinal puncture to 
 determine the possible presence of asymptomatic syphilis of the central 
 nervous system. 
 
 Syphilis of the central nervous system, especially the early stages of tabes, 
 always demands energetic treatment. In addition to intravenous injections 
 of arsphenamine many syphilographers and some neurologists advocate 
 intraspinal treatment. The treatment devised by Swift and Ellis and 
 modified by Ogilvie is carried out as follows : 
 
 The patient receives an intravenous injection of arsphenamine. One 
 hour later 40 c.c. to 50 c.c. of his blood is drawn aseptically from a vein, 
 the blood allowed to clot, its serum separated and placed on ice until 
 next day. It is then centrifuged, one-quarter to one-half milligram of ars- 
 phenamine in solution added and the serum inactivated at 56° C. for forty 
 minutes. It is then ready for use. A lumbar puncture is made, an amount 
 of spinal fluid removed equal to the volume of serum, 12 c.c. to 15 c.c, it is 
 intended to inject, then 15 to 20 c.c. of the spinal fluid allowed to flow into 
 a funnel-shaped vessel where it is mixed with the prepared serum and the 
 whole — the spinal fluid plus the serum — is made to flow by gravity into the 
 subarachnoid cavity. The patient remains recumbent a number of hours 
 after the operation. The injections are repeated at two weeks' interval, six 
 to eight injections constituting a course and two courses are given in a year. 
 The value of this treatment is not universally admitted; it is my belief, 
 however, that cases of tabes in which destructive lesions are not far advanced 
 are greatly benefited by intraspinal treatment, symptoms are relieved and 
 the disease checked. In paresis which is clinically recognizable little or no 
 benefit results from the treatment. An early serological or laboratory 
 
646 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 diagnosis of paresis has never more than a certain degree of probability. 
 The spinal fluid of the paretic always yields a "paretic gold-sol curve," 
 together with pleocytosis, albunhnosis and a positive Wassermann, but 
 similar findings are observed in other, non-paretic, syphilitic affections 
 of the central nervous system and these cases do well under treatment. 
 
 In pregnancy the problem is to prevent infection of the fetus by keeping 
 the blood of the mother free from active spirochetes. Before the end of the 
 third month of pregnancy when placental circulation is established, energetic 
 treatment with arsphenamine and with moderate doses of mercury lest the 
 kidneys be injured should be administered; after that period arsphenamine 
 and mercury should be given in short courses with short periods of rest; 
 one injection of arsphenamine, four weeks of mercury and one month of 
 rest. In pregnancy in the asymptomatic Wassermann-positive syphilitic 
 of the later stages, the intervals between treatment may be longer.] 
 
 YAWS. 
 
 Yaws — also known as plan and framboBsia tropica — is a contagious 
 and inoculable disease of hot countries, which manifests itself by 
 crusted papulo- or pustulo-vegetative eruptions and is caused by 
 a spirochete. 
 
 Yaws is endemic and widely distributed in Indo-China, certain 
 parts of the Indies, the Malaysian Islands, Oceanica, equatorial 
 Africa, Central and Southern America. 
 
 After an incubation period lasting from fifteen days to six months, 
 the invasion manifests itself by general symptoms, a slight fever, 
 digestive disturbances, headache, bone and joint pains and then by 
 a furfuraceous scaly itching eruption (Fig. 185). 
 
 In other cases a primary sore known as the yaws-chancre or the 
 yaws-matrix develops at the site of inoculation, that is, most 
 commonly on the legs or in the face; this lesion may for a long time 
 remain solitary or it may blend with a generalized eruption of the 
 same type. This so-called chancre really has the same objective 
 features as the lesions which follow it (p. 250), frambesia being a 
 monomorphous disease. Glandular enlargement is inconstant. The 
 eruptions spread over the entire integument, lasting several months 
 and following each other during a number of years. The mucous 
 membranes invariably escape. There is no alopecia. Visceral 
 lesions of yaws are unknown. 
 
 No human race is exempt from yaws. The disease is inoculable 
 and extremely contagious, even indirectly, but it is not venereal. 
 It is usually contracted during childhood, favored by some excoria- 
 tion or ulceration which serves as the portal of entry of the virus. 
 Stinging insects may contribute to its dissemination. It is not 
 hereditary. In the course of the first weeks or months, auto-inocula- 
 tion is still possible; after this time, a relative immunity becomes 
 established, which, however, is not always permanent. 
 
 Analogies and a possible relationship between syphilis and yaws 
 
YAWS 
 
 647 
 
 have Jong been noted, but there are considerable differences: syphilis 
 is universally distributed, is not auto-inoculable, has a prescribed 
 course and polymorphous, non-pruritic manifestations; it frequently 
 involves the mucous membranes and the viscera; moreover, it is 
 hereditary. 
 
 The pathogenic agent of yaws, discovered by Castellani in 1905, 
 is the spirocheta pertenuis or pallidula; it is a spiral organism, 
 morphologically very similar to the treponema of syphilis. Noguchi 
 has grown it in cultures. So far it has been found only in the yaws- 
 lesions themselves, but not in the blood and the secretions. Yaws 
 
 Fig. 185.— Yaws. Courtesy of Dr. E. B. Vedder (Knowles). 
 
 is inoculable into monkeys and even into rabbits. It does not confer 
 immunity against syphilis either in man or animals and syphilis 
 on the other hand does not immunize against yaws. But the extract 
 of yaws-papules and the serum of human beings or animals having 
 yaws or cured of the disease, yields a positive Wassermann reaction. 
 The former modes of treatment have been abandoned since the 
 surprisingly rapid and complete action of the arsenobenzols has 
 been recognized. Sometimes one intravenous injection proves 
 sufficient. One month after the introduction of this remedy the 
 large yaws-hospitals in Batavia were closed. In countries where 
 
648 
 
 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 framboesia tropica prevails, the most trifling wounds must be care- 
 fully dressed as they might serve as an entrance-portal for the 
 
 infection. 
 
 LEISHMANIOSES. 
 
 Leishmania (R. Ross, 1903) arc protozoa related to the trypano- 
 somes, the herpetomonas, etc.; they assume the shape of oval or 
 pyriform corpuscles, from '2 to 4^ in length by H to 3/* in width, 
 containing two chromatic masses known as the karyosome and the 
 centrosome; in cultures they present a flagellate stage. They are 
 found particularly in the endothelia, the leukocytes, the connective 
 tissue and in macrophagic cells and exceptionally in the blood of 
 their hosts. 
 
 Fig. 186.— Orient! 
 
 Oriental Boil (Furunculus Orientalist.- This dermatosis, which 
 is endemic in many subtropical or tropical regions in the north of 
 Africa. Eastern Asia, Central and South America, also hears the 
 names, according to the different countries, of Biskra boil, Aleppo 
 boil, Gafsa boil, Nile boil and Delhi boil; Salek or one-year boil in 
 Persia, date-boil, and so forth. 
 
 It is characterized by pustular and ulcero-vegetative lesions 
 which develop without impairment of the genera] health, most 
 commonly in the fall or during the cool season of the year. 
 
 After an incubation of ten days to a month, sometimes longer, a 
 red spot makes its appearance, which becomes papular and pruritic, 
 resembling a mosquito bite; next, the lesion become covered with 
 scales or, as the result of scratching and excoriat ion, with crusts 
 which conceal a slowly spreading oozing ulcer with a wavy outline 
 (Fig. 186); it frequently has the appearance of a furuncle or crusted 
 
LEISHMANIOSES 649 
 
 ecthyma before assuming the characteristic features of its adult stage, 
 which have been described elsewhere in this book (p. 250). 
 
 The lesions are preferably situated on the exposed parts, the hands, 
 the face and the limbs. As a rule, no more than three or four are 
 present, sometimes only one, very rarely from thirty to forty; they 
 develop in succession and are therefore of different ages. The 
 mucous membranes are seldom affected. 
 
 Oriental boil is inoculable and contagious; it confers only a 
 temporary immunity. The blood yields a negative Wassermann 
 reaction. 
 
 The pathogenic organism discovered by J. H. Wright (1903) and 
 named by him helcosoma tropicum was classified by Ii. Ross as 
 leishmania tropica or furunculosa. It is very closely related to, 
 although different from, leishmania Donovani, which causes kala- 
 azar. It is found in thin sections stained with carbolized thionine, 
 within the macrophage cells (Nattan-Larrier) ; and more readily 
 in smear preparations treated by the methods of Romanovski, 
 Giemsa, Laveran, etc. 
 
 It was successfully grown in cultures, in a flagellate form, by Ch. 
 Nicolle, who inoculated it into the macacus. Dogs, camels and 
 horses are said to offer no resistance to it. Without positive proof, 
 it is assumed that the transmission of Oriental boil generally takes 
 place through the intermediation of flies, bugs, mosquitoes or other 
 stinging insects, especially since Nattan-Larrier was able to demon- 
 strate the presence of leishmanias in human blood in the vicinity of 
 the lesions. 
 
 The treatment consists either in excision of the lesions or in 
 scraping followed by cauterization with the actual cautery or 
 applications of potassium permanganate in powder form. The 
 efficacy of the arsenobenzols is variously estimated. In Brazil, intra- 
 venous injections of antimony tartrate are advocated, in doses of 0.05 
 to 0.10, in sterilized solutions of 1 to 100 or 1 to 500 in physiological 
 salt solution; these injections actually seem to be very efficacious. 
 When the patient leaves the countries where the disease is endemic, 
 cutaneous leishmaniosis tends to heal spontaneously; so that in 
 temperate zones clean dressings may be considered as sufficient. 
 The cure may be hastened by radiotherapy. 
 
 Pian-Bois. — This dermatosis is endemic in Guyana among foresters 
 and hunters. Together with de Christmas, I was enabled to observe 
 a case characterized by subcutaneous nodules opening on the 
 skin as ulcers with a granulating floor; the lesions were situated 
 on the back of the hands and arranged at intervals along the lym- 
 phatics of arm. The glands become indurated. The course is slow 
 and the disease may recur. Nattan-Larrier (1909) discovered the 
 pathogenic agent which is a leishmania, present in rather scanty 
 
650 INFECTIOUS DERMATOSES DUE TO PROTOZOA 
 
 numbers, possessing certain special features and named by him the 
 American variety of Leishmania tropica. 
 
 Boubas or Framboesia Brasiliana. -The disease described under 
 this name by Breda, B. Summer and others, differs from yaws in 
 its course and also in that it less frequently spares the buccal, 
 pharyngeal, laryngeal, nasal, conjunctival mucous membranes, 
 etc. The initial lesion is a bulla or a pustule, which is followed by 
 a superficial slough; next appears one or several ulcero-prolifera- 
 tive, painless and non-pruritic lesions in patches; the condition may 
 last ten or fifteen years or longer and cause death from cachexia. 
 Children are rarely attacked and the contagiousness is apparently 
 slight. 
 
 Boubas were attributed by Breda to a bacillus discovered by him 
 in the lesions; Fiocco succeeded in growing this bacillus in cultures 
 and inoculating it into rabbits. However, Splendore and Carini 
 (1911) have shown that the disease represents a leishmaniosis. 
 
 Espundia, described by Escomel, endemic in Peru, Brazil and 
 other parts of South America, begins on the limbs or on the trunk 
 with a nodule which opens as an ulcer with a granulating floor, 
 discharging abundantly and not particularly painful; ulcerative- 
 granulating and destructive bucco-naso-pharyngeal lesions next 
 make their appearance; the duration is twenty to thirty years. 
 Buono de Miranda and Splendore discovered a leishmania which is 
 considered by Laveran and Xattan-Larrier (1912) as belonging to 
 the American variety of Leishmania tropica. [According to Escomel 
 (1919) the lesions of blastomycosis are sometimes associated with 
 those of espundia in the same case.] 
 
 Espundia, Bouba, perhaps also Pian-Bois, are therefore probably 
 identical diseases, namely Leishmaniasis Americana. 
 
 Injections of tartar emetic are recommended as in the treatment 
 of Oriental boil; arsenobenzol is useless. 
 
CHAPTER XXX. 
 
 DERMATOSES OF THE LEUKEMIAS AND ANALOGOUS 
 PATHOLOGICAL CONDITIONS. 
 
 CUTANEOUS LEUKEMIAS. 
 
 In a large number of the skin diseases which have been previously 
 discussed, a change in the cellular composition of the blood can be 
 demonstrated. Not to mention anemia and leukocytosis which 
 are of common occurrence in many infections or toxic diseases of the 
 skin and even in the neurodermatoses, it suffices to point out that 
 a sometimes very considerable eosinophilia is noted in pemphigus 
 and especially in Duhring's disease, where the local eosinophilia is 
 still more marked; in cutaneous hydrargyria, likewise with local 
 eosinophilia (Hoffmann) ; in leprosy, especially the tubercular form ; 
 it has finally been reported in some cases of erythema, urticaria, 
 eczema, etc. However, the relations between these eruptions and 
 the modification of the blood are neither absolutely constant nor 
 probably direct. 
 
 The cutaneous affections to be dealt with in this chapter are on 
 the contrary closely related to organic alterations of the blood or, 
 more accurately speaking, with one or other of the hyperplastic 
 diseases of the hematopoietic organs which are grouped under the 
 heading of leukemias and analogous pathological conditions. It is 
 therefore indispensable for the dermatologist to be informed on the 
 subject of these general diseases. 
 
 Since the investigations of Ehrlich, a distinction is made between 
 two fundamental forms of leukemia: (1) The lymphatic leukemias 
 in which the hyperplasia affects the glands and adenoid structures 
 of the same kind, tonsils, closed follicles of the intestine, thymus, etc., 
 including also the spleen; (2) the myeloid leukemias in which the 
 lesions affect the bone-marrow and the myeloid tissues, among 
 which the spleen, as an organ of mixed structure, again figures. 
 
 These hyperplasias are accompanied by the passage of their con- 
 stituent cells into the bloodstream, sometimes in enormous propor- 
 tions, for from 100,000 to over 500,000 white corpuscles per cubic 
 millimeter may be found (true leukemias). In other cases, this 
 passage takes place to a limited degree and no more than 20,000 to 
 30,000 white corpuscles are found in the blood, or even a normal 
 number (pseudo-leukemias, subleukemias, aleukemias) : but in all 
 
652 DERMATOSES OF THE LEUKEMIAS 
 
 cases the customary proportion of the different kinds of white 
 corpuscles, the leukocyte formula, is modified, so that there may be 
 for example a relative lymphocytosis or submyelemia; all degrees, 
 subject to variations, may be observed in the same case; a sub- 
 leukemia may even become transformed into a true leukemia. 
 
 The leukemias and pseudoleukemias are chronic diseases, usually 
 lasting from two to six years or longer; relatively recent observations 
 have shown the existence of a rapid form, leading to death in a few 
 weeks or months and constituting acute leukemia. 
 
 There is at present a tendency among hematologists to group 
 under the heading of lymphomatosis all the hyperplastic affections 
 of the glandular or adenoid system, whether leukemic or not, chronic 
 or acute, generalized or localized; and under the heading of myelo- 
 matosis those of the myeloid system. The principal forms of these 
 are outlined in the following: 
 
 Clinical Forms.— Chronic lymphatic leukemia begins insidiously 
 with fatigue, emaciation, hypertrophy of the glands, at first often 
 with a submaxillary, parotid and cervical and later generalized 
 localization, almost invariably associated with an enlarged spleen 
 and sometimes with hypertrophy of the liver. The white corpuscles 
 of the blood, greatly increased in number, are lymphocytes in a pro- 
 portion of .10 to 95 per 100. Histological examination of the glands 
 and other hematopoietic organs shows an enormous hyperplasia 
 of the adenoid tissue (lymphadenia) which is swollen and packed 
 with practically pure lymphocytes; the other organs and viscera 
 may be the seat either of leukemic infiltration or of true lymph- 
 adenomas. 
 
 Aleukemic lymphomatosis (also subleukemic or aleukemic lymph- 
 adenia, Trousseau's adenia, Hodgkin's disease, pseudoleukemia of 
 Cohnheim) differs from the above only by the subleukemic or 
 aleukemic condition of the blood. Aside from its progressive and 
 generalized form, there exist localized forms limited to certain 
 groups of glands (neck, mediastinum, abdomen, etc.) or to an adenoid 
 organ (tonsil, intestine), which may develop like a neoplasm and will 
 be referred to later. 
 
 Chronic myeloid leukemia, the onset of which is very obscure, 
 manifests itself in its stationary stage by an enormous spleen with 
 a large liver, without glandular enlargement, and by a pale com- 
 plexion; the blood ordinarily contains about 300,000 white corpuscles 
 the majority of which are granular (polynuclears and myelocytes 
 with neutrophile granules, basophiles and eosinophil , myeloblasts 
 and nucleated rv(\ cells); the bone-marrow is gray or whitish and its 
 constituents are actively proliferating; there is myeloid transfor- 
 mation of the spleen and accessorily a myeloid infiltration of the 
 lymphatic system and the liver; there may be myelomatosis of the 
 
CUTANEOUS LEU KE MI AS 653 
 
 perivascular tissue in the entire organism. The subleukemic forms of 
 this disease (submyelemic splenomegalies) are rare and still a subject 
 of controversy. 
 
 Acute leukemia, which occurs in a not easily distinguishable 
 lymphatic form and a myeloid form, behaves like an acute infection. 
 The onset is marked by chills, splenic pains, general fatigue and often 
 by angina with persistent fever. The dominating features in the 
 clinical picture consist in the following: Sometimes, moderate 
 glandular hypertrophies, especially at the neck, reaching the tracheo- 
 bronchial glands with mediastinal symptoms or the mesenteric 
 glands with hypertrophy of the spleen; other cases are associated 
 with hemorrhages, epistaxis, hematemesis, melena, etc., or with 
 buccopharyngeal symptoms, angina, pseudoscorbutic gingivitis; 
 also nervous disturbances, such as headache, vertigo and asthenia. 
 The blood contains over 50,000 white corpuscles, which have reached 
 an imperfect maturity, large lymphocytes or lymphoblasts, or very 
 polymorphous macrolymphocytes. The lesions of the organs are 
 the same as in the chronic forms, but with proliferation and infiltra- 
 tion of large undifferentiated lymphocytes. 
 
 Aside from these typical forms of lymphomatosis and myeloma- 
 tosis, atypical forms are not very infrequently encountered; such as: 
 
 Regional glandular lymphadenoma, without leukemia, not easily 
 differentiated from tuberculous adenopathy; 
 
 Lymphosarcoma of Kundrat-Paltauf, which presents itself as a 
 malignant glandular tumor, at first regional, with a tendency to 
 become generalized, invading the adjacent organs by infiltration 
 and spreading by metastasis {lymphosarcomatosis); it is accompanied 
 by a moderate neutrophilia ; 
 
 Chloroma (or green cancer of Aran), characterized by tumors of 
 the cranial periosteum and lymphomas of a greenish hue in all the 
 hematopoietic organs, with lymphoid or myeloid subleukemia; 
 
 Lymphogranulomatosis (of Sternberg-Paltauf ) , a progressive 
 glandular hypertrophy, capable like lymphosarcoma of invasion 
 and production of metastases, is differentiated from aleukemic 
 lymphomatosis by the presence of yellowish gray points in cross- 
 sections and by a mixed lymphoid and myeloid structure analogous 
 to the structure of wound-granulations, hence its name of granuloma 
 (Benda); it is accompanied by a moderate leukocytosis. This 
 pathological type, which has not been extensively studied in France, 
 corresponds according to Gravitz and others to the majority of 
 cases of Cohnheim's pseudoleukemia and Hodgkin's disease. Several 
 authors interpret it as an attenuated tuberculosis, a genuine glan- 
 dular "tuberculide." 
 
 Etiology and Character. — The etiology of the leukemias and dis- 
 eases of the same group is entirely unknown. 
 
654 DERMATOSES OF THE LEU KE Ml AS 
 
 They were originally supposed to be of neoplastic character and the 
 name of" cancer of the blood" (Bard) was actually suggested for these 
 cases. As a matter of fact, the indefinite cellular proliferation of 
 certain lymphomas and myelomas, the atypical cell-forms met with 
 in certain varieties, the invasion of the vicinity and the metastases, 
 the terminal cachexia, closely simulate the malignant tumors. It is 
 undeniable that the boundaries between lymphadenomas, lympho- 
 sarcomas and sarcomas arc not very sharp at the present writing. 
 
 On the other hand, a large array of facts, notably the existence 
 of acute febrile forms of the leukemias is in favor of their infectious 
 character. There is in all probability no reason to look for a 
 "microbe of the leukocythemias" and isolated findings along this 
 line of inquiry have not been confirmed. Cultures and inoculations 
 into animals are generally unsuccessful; in a well-marked case of 
 acute leukemia, I carried out inoculations of blood and tissue-parts 
 into two monkeys without result. But the frequency in the patient's 
 antecedents of various infectious diseases, eruptive fevers, anginas, 
 especially of syphilis and tuberculosis, as well as the analogy in the 
 course of certain lymphomatoses and lymphogranulomatoses with 
 the tuberculous adenopathies are suggestive of a less simple inter- 
 pretation. Possibly, various attenuated infections or those which 
 develop on an allergic soil, excite a reaction which after being at 
 first defensive, reconstructive and hyperplastic, ultimately becomes 
 atypical, destructive and offensive for tissues of the same kind or 
 those which have been invaded in the vicinity or at a distance; the 
 process, inflammatory at the onset, might in this way acquire the 
 attributes of a malignant neoplasm. 
 
 Cutaneous Manifestations. — These may be observed in all the 
 forms, chiefly in the subleukemic or aleukemic lymphomatoses 
 (pseudoleukemias), in chronic lymphatic leukemia, in the acute 
 leukemias, in the case of lymphosarcoma, lymphogranulomatosis, 
 etc. ; they are less common in chronic myeloid leukemia, but never- 
 theless undeniable (Brunsgaard, Lian). They do not differ among 
 themselves according to the type of disease in which they occur; in 
 the very noteworthy and learned contribution of Xanta to the study 
 of the lymphodermas and myelodermas (Annales de Dermatologie, 
 1912), this author agrees with his predecessors in stating that the 
 blood-formula has no bearing on the aspect of the cutaneous lesions. 
 
 Besides being extremely variable and multiple, these cutaneous 
 manifestations are often polymorphous in the same case. They may 
 be persistent or transitory, delayed or premature, sometimes pre- 
 ceding the glandular or splenic enlargement and the changes in the 
 blood. 
 
 From an objective point of view, they may be divided into three 
 groups: 
 
PLATE III 
 
 / 
 
 . 
 
 Leukemic Tumors of the Cheek, Nose and Lobule of the Ear, 
 in a Case of Leukemic Lymphomatosis. 
 
CUTANEOUS LEUKEMIAS 655 
 
 1. Some are of very dissimilar and rather ordinary appearance; 
 representing the leukemides of Audry and his pupil Germer (These, 
 1902). They consist either of persistent pruritus with dryness of 
 the skin; or of pruriginous exanthemas in the form of urticaria, 
 sometimes of papular or vesicular urticaria, simulating polymor- 
 phous erythema or Duhring's disease; or the lymphadenic prurigo 
 of Dubreuilh (p. 495) which is accompanied by papules and licheni- 
 fication. Patches of eczematization also occur, probably due to 
 scratching, as well as pyodermatitides through superadded infec- 
 tion, leaving pigmented macules and small cicatrices. Finally, there 
 may be eruptions of purpura with easily provoked hemorrhages. His- 
 tology has only rarely been able to demonstrate miliary lymphomas 
 in certain leukemides, such as prurigo papules. 
 
 2. Leukemic erythrodermas have been described which do not seem 
 to constitute a generic type. Some cases are perhaps generalized 
 eczemas; others are premycotic erythrodermas (p. 119) ; finally, some 
 (Nicolau, Annates de Dermatologie, 1904) present themselves under 
 the aspect of generalized exfoliative dermatitis or of pityriasis rubra 
 with relative lymphocytosis. In this connection the famous case of 
 Kaposi (1885), entitled lymphodermiaperniciosa. is invariably quoted; 
 this was characterized by moist and scaly redness, pruritus, a doughy 
 thickening of the skin, followed by cutaneous and subcutaneous 
 nodosities which became ulcerated; hypertrophy of the glands and 
 of the spleen, genuine leukemia, developed rapidly and the patient 
 promptly died; the case was probably one of mycosis fungoides, 
 beginning with erythroderma and terminating as lymphatic leukemia 
 
 3. Leukemic tumors and infiltrations are more characteristic. 
 There exists a localized clinical form, situated anywhere, but often 
 on the face; in these cases, flabby and painless, purplish or brownish- 
 red tumors, with a thin smooth skin, traversed by telangiectases, 
 are seen to develop on the cheeks, the nose and the ears; the swel- 
 lings slowly increase in size, without a marked tendency to necrosis 
 and ulceration. I have had occasion to follow a case during fifteen 
 years (Plate III). They may be found on the mucous membranes. 
 Sometimes, the condition consists rather of diffuse purplish infil- 
 trations in which vitropressure shows translucid miliary nodules. 
 
 Another form presents small red, bluish or dusky tumors, some- 
 times resembling lepromata. In a case of acute leukemia in a child 
 of thirteen years, I noted very numerous nummular lilac patches, 
 marking the site of not very prominent dermo-hypodermic nodosities 
 distributed over the thorax, abdomen, forehead and scalp. 
 
 The structure of these newformations is that of lymphomata 
 or lymphadenomata; small or medium-sized lymphocytes (lympho- 
 blasts or macrolymphocytes) fill the meshes of a fine adenoid network 
 which is supported by the vascular walls. 
 
656 DERMATOSES OF THE LEUKEMIAS 
 
 In other cases, which seem to me relatively less uncommon, there 
 exist multiple cutaneous tumors, some of which are voluminous 
 
 and occasionally undergo necrosis and ulceration; their structure 
 comprises cells of various types, a considerable number having the 
 characteristics of the constituents of lymphomata or myelomata, 
 although more or less modified and atypical; these cells are enclosed 
 in a network with strands of variable thickness, fairly large in places 
 and provided with connective-tissue cells. These are cases of 
 lymphosarcoma and lymphosarcomatosis, whose relations with the 
 leukemias are doubtful and which closely approximate the sarcomas. 
 
 Diagnosis. In a general way it may be stated that whenever the 
 physician finds himself confronted with a cutaneous manifestation 
 which may be a leukemide, a leukemic erythroderma, or a lympho- 
 matous or myelomatous tumor, he should keep in mind the leukemic 
 and pseudoleukemic states and look for their symptoms. 
 
 In the presence of a coexisting progressive glandular hypertrophy 
 or splenic hypertrophy, with corresponding general phenomena and 
 the characteristic lesion of the blood, all doubts are removed. 
 
 When no such coexistence is found at the time of the first exami- 
 nation, it is advisable not to discard too hastily the idea of a possible 
 relation between the skin affection and an as yet undeveloped 
 leukemic state, but this should on the contrary be looked for very 
 carefully [by repeated examinations of the blood at intervals of one 
 or two weeks]. 
 
 This rule is especially imperative in case of tumors of ambiguous 
 character which may be leukemic, lymphosarcomatous or sarcoma- 
 tous. Laboratory procedures should be called upon to assist the 
 clinical examination; in addition to careful control of the hemato- 
 poietic organs by repeated serial hematological examinations, recourse 
 must be had to biopsy, either of carefully selected eruptive lesions 
 or of tumor fragments and possibly of a lymph gland. Fixing agents 
 and stains applicable to the cytological examination of the constitu- 
 ents, notably those of the myeloid series, must be employed. 
 
 In attempting to decide between the diagnosis of a lymphoma or 
 a sarcoma, for example, the following considerations must not be 
 losl sight of: the criterion of the "adenoid plexus" is by no means 
 entirely conclusive; it is not always possible to distinguish the cells 
 derived from the blood (hematogenous) from the cells originating 
 locally in the tissues (histogenetic) ; although it is true in a general 
 way that the constituents of lymphomata are merely infiltrated 
 into preexisting tissues whereas those of sarcomata replace the 
 latter, this is not a reliable feature since the leukemic constituents 
 are known to possess the power of local multiplication through 
 karyokinesis; one may go so far as to admit, with Dominici and 
 others, the possibility of a primary development of lymphoma in the 
 
MYCOSIS FUNGOIDES G57 
 
 skin, as a mesenchymatous tissue, more particularly around its 
 vessels, through a revival of its fetal hematopoietic properties. 
 
 It is only at the expense of persevering investigations along this 
 line that we may hope to encounter favorable cases permitting a 
 better understanding of the cutaneous lymphomata and myelomata 
 as well as their relations with the malignant connective-tissue 
 tumors or sarcomata. 
 
 MYCOSIS FUNGOIDES. 1 
 
 Mycosis fungoides was first separated and named by Alibert and 
 accurately described by Bazin; it is also known as cutaneous 
 lymphadenia of Ranvier, Gillot and Demange and as granuloma 
 fungoides of Auspitz. It is a chronic general disease, taking an 
 irregular course, almost invariably fatal, relatively rare and of 
 unknown nature. 
 
 Symptoms. — Mycosis fungoides manifests itself by very diverse 
 eruptions and special tumors of an always identical structure. 
 
 The onset, which is extremely insidious, may take place in four 
 different ways: (1) as a generalized and prolonged pruritus, with 
 nothing to account for it in the beginning; (2) as polymorphous 
 premycotic eruptions, to be described presently; (3) as a premycotic 
 erythroderma (p. 119); (4) as primary tumors. 
 
 The polymorphous 'premycotic eruptions are transitory or per- 
 sistent; they assume the form of erythematous, roseolar, urticarial, 
 circinate or erysipeloid spots or patches; of eczematizations prob- 
 ably due to scratching; more rarely, of purpura, crops of vesicles 
 or bullae, or of pyodermatitides. Sometimes there are more station- 
 ary infiltrated patches known as eczemato-lichenous patches, with 
 irregular outlines, continuous or interwoven, slightly prominent, of 
 a yellowish or purplish red color, which are the seat of severe itching. 
 This surface may be scaly, oozing or crusted; or again, which is 
 more significant, it may be criss-crossed as in lichenization. The 
 number, the distribution and the duration of these premycotic 
 eruptions are too variable to permit of a description. 
 
 In the developed stage, the usual findings are as follows: (1) 
 Extensive eczematiform and lichenized surfaces, with edema of the 
 skin, diffusely covering the face which thereby acquires a fairly 
 characteristic leontiastic appearance; nearly the entire integument 
 may be involved, although islands of healthy skin are almost 
 invariably demonstrable; (2) infiltrated patches, of a brick red 
 
 1 In the first edition of this book, this disease is discussed under the infectious 
 dermatoses; this classification, although based upon undeniable analogies, was not 
 supported by proof. I now classify it with the cutaneous leukemias, with which it 
 definite affinities, 
 42 
 
658 
 
 DERMATOSES OF THE LEUKEMIAS 
 
 color, of variable extent, with an orange-peel or mammillated sur- 
 face; (3) mycotic tumors (Fig. 187). 
 
 The latter, at their onset of the size of a cherry to that of half a 
 mandarin orange, originate on one of the preceding lesions or some- 
 times in healthy skin; they are more or less soft, of a dark red color, 
 hemispherical, not infrequently constricted at their base, umbili- 
 cated and indented, so that they have been compared to a tomato; 
 they may, however, assume a semicircular, crescentic or polycyclic 
 form. They often become ulcerated, through superficial erosion or 
 through central necrosis, while spreading peripherally. 
 
 Fig. 187.- 
 
 -Mycosis fungoides. Extensive eczemato-lichenous patches of the back, 
 with partially ulcerated mycotic tumor. 
 
 There result enormous ulcerated tumors which may become 
 conglomerated and attain the size of an adult's head, or large ulcers 
 with a ragged, sanious, gangrenous floor, bordered by a fungoid 
 elevation. 
 
 It is a remarkable fact that these tumors may at any stage become 
 absorbed and disappear spontaneously, leaving no trace, or being 
 followed merely by a soft white cicatrix with a pigmented areola; 
 other tumors then form in proportion at different points of the body. 
 
 They are situated especially on the trunk, the face and on the 
 first segments of the limbs, 
 
MYCOSIS FUNGOIDES 659 
 
 The glands are sometimes enlarged early in the disease. From 
 the start any preexisting nevi become swollen simulating incipient 
 tumors. Alopecia of the affected regions is the rule. 
 
 The course extends over a period of from two to twenty years, 
 interrupted by spontaneous remissions which may simulate a cure. 
 The patient's strength, complexion, weight and digestive functions 
 finally become impaired and death occurs in marasmus or as the 
 result of a complication. 
 
 In the form with primary tumors (a tumeurs d'emblee), described 
 by Vidal and Brocq, the tumors are discrete and restricted to one 
 region of the body, originating in healthy skin or on non-pruritic 
 patches, without swelling of the glands ; they may become absorbed 
 without ulceration. This type is very closely related to the sarco- 
 mata according to Brocq; it also approximates the leukemic 
 tumors. 
 
 Pathological Anatomy. — In a contribution of mine to the study of 
 the premycotic eruptions (1910), I showed that those which are 
 clinically of ordinary appearance, for example eczematous or lichen- 
 oid, have nothing unusual in their histology; the demonstrable 
 changes of acanthosis, papillomatosis, spongiosis, exocytosis and 
 partial parakeratosis are those of eczematization due to scratching. 
 A biopsy at this stage of the disease would therefore not help the 
 diagnosis. 
 
 Premycotic erythroderma, on the contrary, has a characteristic 
 structure (Fig. 29) ; namely, that of the mycotic tumors, but spread 
 out as a thin layer in the papillary body; often the intra-epidermic 
 cellular nests which are peculiar to mycosis are demonstrable, 
 differing through their sharp boundaries from the small islands of 
 spongiosis seen in eczema. 
 
 The mycotic tumors are uniformly composed of a tissue of lympho- 
 matous appearance, which led the first observers (Ranvier, Gillot, 
 etc.) to the assumption of a "cutaneous lymphadenia." A fine 
 adenoid network, its strands resting upon the vascular walls, is 
 packed with a variety of cells. The great majority of these — 
 rounded or polygonal, approximately the size of a polynuclear cell, 
 with a round or variably deformed nucleus, with more abundant 
 protoplasm than that of a lymphocyte, sometimes containing baso- 
 philic granules — seem to be atypical myelocytes of lymphoblastic 
 origin. Furthermore, there are found, in variable proportions, 
 connective-tissue cells, small lymphocytes, large mononuclears, 
 sometimes chorioplasts or giant cells, plasmocytes and mast-cells. 
 Pautrier and Fage in an interesting case encountered a large number 
 of eosinophiles and mast-leukocytes, apparently formed locally at 
 the expense of the lymphocytes. In a general way, there is marked 
 predominance of a certain variety of lymphoid cells, with distinct 
 
660 DERMATOSES OF THE LEU KE MI AS 
 
 polymorphism of the other constituents. Many karyokinetic 
 
 figures are found. 
 
 The epidermis of the tumors is hyperacanthotic at their borders, 
 eroded or missing in ulcerated eases. Sometimes large numbers of 
 "cell nests" (Fig. 29, a) are found, filled with lymphoid eells. 
 
 The composition of the blood is not uniform in all eases and varies 
 in the course of evolution of a given ease. A certain degree of 
 anemia and eosinophilia is rather common; neutrophile poly- 
 nucleosis is not rare; sometimes, a slight myeloid reaction has been 
 noted. The leukemia or leukocytosis which have repeatedly been 
 demonstrated in the terminal stage, is difficult of interpretation. 
 
 Nothing very definite is known concerning the character of the 
 visceral lesions which have been found rather frequently in the 
 lungs, the kidneys, the suprarenals and more rarely in the serous 
 membranes, the bone-marrow and the liver of mycotic patients; 
 Brandweiner found metastatic tumors in the brain, with the same 
 structure as those of the skin. This matter requires further investi- 
 gation. 
 
 Etiology and Character. — Mycosis fungoides is known to be neither 
 hereditary nor contagious. It is encountered somewhat more 
 frequently in men than in women, especially between the age of 
 thirty and fifty years. [In the American Dermatological Associa- 
 tion's statistics it occurred once in about 3000 cases of all skin 
 diseases.] 
 
 The etiology and character of the disease are still problematical. 
 A large array of arguments is in favor of its infectious character, 
 although no parasitological or experimental proof has so far been 
 furnished. To admit its sarcomatous character, with Kaposi, 
 means to strain the analogies and to content oneself with a word. 
 While it is no longer possible to maintain that mycosis fungoides 
 is merely the cutaneous form of lymphadenia, it must be recognized 
 that it is nevertheless most closely related to the lymphodermas, 
 myelodermas and especially the lymphogranulomatoses which are 
 infectious neoplasms. It is especially important to keep in mind 
 cases which are known to have terminated in leukemia. Some day 
 it ma}' be discovered that mycosis fungoides is based upon a reaction 
 of the lymphoid or myeloid apparatus, under the influence of still 
 unknown or variable pathogenetic agents. 
 
 Diagnosis. — At the onset a diagnosis may be impossible. The 
 persistence of polymorphous erythematous, eczematous, lichenoid 
 eruptions or of erythroderma, especially when presenting the feature 
 of the edematous infiltration which I have emphasized and when 
 associated with severe itching, should arouse a suspicion of pre- 
 mycotic manifestations. In such cases, biopsy is necessary, but I 
 have already pointed out that the histological lesions are often com- 
 
MYCOSIS FVNGOIDES CGI 
 
 monplace and possess diagnostic value only in so far as they approach 
 those of premycotic erythroderma. 
 
 In the stage of infiltrated patches and tumors, the clinical picture 
 is very characteristic; but before making a diagnosis of such 
 serious import, it should be confirmed by histological examination 
 and blood-analysis. The sero-diagnostic method of complement- 
 fixation with an extract of mycotic tumors serving as the antigen, 
 proposed by Gaucher, Brin and Joltrain, has yielded encouraging 
 but still unreliable results. 
 
 Treatment of Mycosis Fungoides and Cutaneous Leukemias. — The 
 periods of spontaneous improvement which are apt to interrupt the 
 clinical course of mycosis and the chronic leukemias make it difficult 
 to estimate the efficacy of the treatment instituted. It is reasonable 
 and entirely indicated to treat the premycotic eruptions, the erythro- 
 dermas and the more or less ordinary leukemides locally, according 
 to their eczematous or pruriginous appearance, etc., like the analo- 
 gous skin affections, often with real benefit to the patient. 
 
 Ulcerated tumors should be cleansed, dressed aseptically, tam- 
 poned with camphorated naphthol, etc. Sometimes the absorption 
 of tumors and infiltrations has been brought about by means of 
 topical applications of pyrogallol, the employment of which neces- 
 sitates careful control of the urine; or other reducing agents may 
 be used. Surgical removal cannot be recommended. Mercurial 
 injections have seemed to me to exert a favorable influence in a few 
 cases of premycosis. 
 
 The fundamental methods of treatment, however, superior to all 
 others, are represented by arsenic and by radiotherapy. The classi- 
 cal employment of arsenic by the mouth or by intramuscular injec- 
 tions in progressive doses, is at present replaced by intravenous 
 injections of novarsenobenzol; the effect may seem to be favorable, 
 but is more apt to be doubtful or negative. 
 
 [In these chronic disorders, the effect of arsenic is developed 
 only when the drug is administered in full doses and over a long 
 period of time. The arsenobenzols exercise their specific effect in 
 syphilis not qua arsenic but because of a peculiar molecular struc- 
 ture which renders them spirocheticidal. They are of value there- 
 fore only in the spirochetal infections. Their action is necessarily 
 too evanescent to be of use when the metabolic effect of arsenic is 
 the object of its administration. I have found arsenic by daily 
 hypodermatic injections in courses of a month to be of decided value 
 in the leukemias, not only in controlling the early eruptions but also 
 in favorably modifying the blood-picture. I use the formula 1$ sodii 
 arsenatis, phenolis, aa 2.0, aquse 100.0. Beginning with 0.5 c.c, 
 the daily dose is gradually increased until it reaches 2.0 or 3.0 c.c. 
 at which point it remains stationary for a week, thence declining 
 
662 DERMATOSES OF THE LEUKEMIAS 
 
 rapidly. The course lasts about a month and may be repeated after 
 a two months' interval. The injections are absolutely painless.] 
 
 On the other hand, it is unanimously conceded that radiotherapy 
 is the treatment of choice in all the diseases of this group. In 
 different cases the glandular masses, the spleen, the bones, or again 
 the tumors or the various cutaneous lesions are exposed to the rays, 
 with or without filter, in carefully regulated doses, using caution 
 and judgment. The rapidity with which the hyperplasias are 
 reduced and the tumors or infiltrations made to disappear, while 
 the leukocyte formula of the blood becomes modified is very remark- 
 able and has encouraged great expectations. It may be stated that 
 although a noteworthy improvement and sometimes more or less 
 lasting apparent cures are thus obtained, no certain and definite 
 cures have as yet been reported. 
 
CHAPTER XXXI. 
 TUMORS OF THE SKIN. 
 
 Tumors or neoplasms are circumscribed, non-inflammatory new- 
 formations having a tendency to persist and increase in size, of 
 unknown etiology. 
 
 The group of tumors was formerly more comprehensive than it is 
 at the present day, for originally all swellings were grouped under 
 this heading; for a very long time, until the discovery of their 
 infectious character, the tuberculomas, syphilomas, lepromas, acti- 
 nomycosis and so forth, ranked as tumors. In a general way, 
 this is a provisional group; as soon as a neoplasm has surrendered 
 the secret of its origin, it ceases to be considered as a tumor and 
 is aligned with the infectious or other diseases; for this reason I 
 regard as justified the introduction of the words "of unknown 
 etiology" into the terms of the definition of neoplasms. 
 
 In a certain number of tumors, although their first cause still 
 escapes us, the pathogenic mechanism to which they are referable 
 can nevertheless be suspected. As a matter of fact, there are alto- 
 gether only three conceivable mechanisms capable of giving rise to 
 pathological neoplasms. These must necessarily be due to: either 
 an original malformation; or to a reaction of the tissues against 
 external injurious agents, a reaction which is described as inflam- 
 matory; or finally to the deposit or retention of elaborated or 
 secreted autochthonous substances. 
 
 Among the tumors of the skin, a considerable number belong to 
 the first group, namely the nevi. 
 
 Others are almost certainly, in spite of the terms of the above 
 definition, of inflammatory or infectious character, as results from 
 their contagiousness or from their structure; such are the warts, 
 molluscum contagiosum, perhaps certain sarcomas, etc. 
 
 As retention tumors may be cited the sebaceous cysts, the 
 xanthomas, the tophi of gout; and perhaps urticaria pigmentosa. 
 
 As to the majority of neoplasms, however, for example, epithelial 
 cancers, their origin remains as yet inexplicable. Furthermore, it 
 must be kept in mind that in the ultimate analysis the three processes 
 are perhaps neither irreducible nor incompatible. It has actually 
 been shown that imperceptible transitions occur between the 
 inflammatory hyperplasias, the nevus-like malformations and the 
 retention-tumors. 
 
064 TUMORS OF THE SKIN 
 
 On the other hand from the point of view of their clinical behavior, 
 although sonic tumors arc benign, behaving simply like an acquired 
 and persistent local deformity, and others are malignant, destructive, 
 invasive and subject to dissemination by metastasis, all intermediate 
 degrees between these two courses are met with, as well as transi- 
 tions from one form into the other. 
 
 On the whole, although it comprises extremely dissimilar affec- 
 tions, this nosographical group of tumors must still be provisionally 
 maintained for the time being. 
 
 Several classifications, clinical, anatomical, pathogenic, have been 
 suggested and can be combined to a certain extent. I shall therefore 
 subdivide this class into three orders: 
 
 1 . Nevi, the nevic tumors really belong anatomically to one of the 
 two following groups; but, it seems to me desirable to present a 
 general survey of these malformations, whether they constitute 
 neoplasms or not. 
 
 '2. Epithelial tumors. 
 
 3. Connective- and Vascular-tissue tumors. 
 
 NEVI. 
 
 Nevi — popularly designated under the names of birthmarks, 
 portwine stains, liver spots, beauty spots, etc. -are congenital mal- 
 formations of the skin, assuming the form of persistent spots or, 
 tumors. Such is their classical definition. 
 
 It has long been known, however, that these deformities are by 
 no means strictly congenital and unchangeable. Many nevi spread, 
 enlarge or diminish in size. Some do not appear until after birth, 
 at the time of puberty or even later. Nor is there any valid reason 
 why the name of nevi should not be applied to certain entirely 
 analogous spots or outgrowths which do not develop until adult 
 life or in old age. 
 
 Nevi would therefore be more accurately defined as circum- 
 scribed deformities of the skin, of embryonic or developmental 
 origin, appearing at any age and taking a very slow course. 
 
 The view according to which nevi are dependent upon emotional 
 or physical disturbances experienced by the mother during preg- 
 nancy, rests on no solid basis. 
 
 Nevi arc of enormous frequency. Individuals entirely free from 
 them are exceptional. The hereditary character of a predisposition 
 for nevi is very obvious and in certain families they arc remarkably 
 abundant. 
 
 Numerous or large nevi are not infrequently met Avith in erratic 
 or feeble-minded persons and idiots, so that they have been desig- 
 nated by some as a hallmark of degeneration, an obviously exag- 
 gerated statement. 
 
MevI 665 
 
 It must be understood that in some cases it is not a question of 
 solitary and as it were accidental products, but of profuse sometimes 
 regional or systematized eruptions of nevi of various types, asso- 
 ciated Math other malformations: Recklinghausen's disease, lenti- 
 ginosis, perhaps xeroderma pigmentosum, etc., to which this remark 
 is applicable, may be considered as nevic diseases. 
 
 Four forms of nevi are recognized: (1) Pigmentary nevi; (2) 
 tuberous non-vascular nevi; (3) adenomatous nevi, in which some 
 of the cysts may be included; these will be discussed with the 
 epithelial tumors; (4) vascular nevi, which will be found under the 
 heading of angiomas. 
 
 1. Pigmentary Nevi. — These are brown or blackish spots, without 
 notable thickening of the skin, of variable shape and dimensions; 
 they may apppear at any age but especially about puberty; they 
 are apt to darken or multiply under the influence of pregnancy, 
 uterine disturbances, or exposure to sunlight. 
 
 (a) Liver spots, thus named on account of their color, are round, 
 oval, or polylobular and may exceed the dimensions of the palm of 
 the hand; aside from its pigmentation, the skin is in no way changed. 
 
 (b) Ephelides (p. 323) are not classified with nevi by the 
 majority of authors. 
 
 (c) Lentigo or lentigines are brown, black or blue spots, about the 
 size of a lentil, situated on the face, the neck, the shoulders or else- 
 where; they are sometimes known in France as "beauty spots." 
 The old writers designated the purely pigmentary flat spots under 
 the name of ncevi spili. Not uncommonly, however, a lentigo is 
 perceptible to the touch and slightly prominent; all intermediate 
 forms may even be met with between lentigo and soft pigmentary 
 verrucous nevi. In the flat spots of lentigo, the pigment is localized 
 in the epidermis exclusively; when the spots are prominent, pig- 
 mentary and nevic cells are found both in the epidermis and in the 
 cutis (Fig. 195). 
 
 Exceptionally, the skin is spattered with lentigo-spots in the form 
 of an abundant eruption, constituting lentiginosis prof it sa. 
 
 (d) Lentigo maligna (infective melanotic freckles of Hutchinson; 
 precancerous circumscribed melanosis of Dubreuilh) is a pigmentary 
 spot which may appear at any age, by no means exclusively in the 
 aged, in any region, although preferably on the face. It has the 
 structure of a diffuse lentigo, spreads slowly at first, then sooner or 
 later gives rise to a nevo-carcinoma and accordingly constitutes an 
 extremely serious affection. 
 
 (e) In progressive cutaneous melanosis, a very rare disease which is 
 more apt to attack the young, a slate-colored or bluish spot is seen 
 to spread slowly, become verrucous, give rise to melanotic infil- 
 tration of the glands and lead to death after a number of years as a 
 
606 TUMORS OF THE SKIN 
 
 result of visceral melanosis. In this form, the pigment infiltrates 
 the connective-tissue cells of the corium. 
 
 The treatment of liver-spots is like that of ephelides. It would be 
 exaggerated to insist upon the destruction of all lentigo spots, but 
 it is advisable to watch them. 
 
 At any rate, it should be kept in mind when treating lentigo, that 
 there is real danger in repeatedly irritating or incompletely cauter- 
 izing the spots, for such measures result only too frequently in the 
 production of melanosis and nevus-carcinoma. (French Association 
 for Cancer Research, November, 1913.) Superficial spots can be 
 destroyed with the galvanocautery ; carbonic acid snow or electrolysis 
 constitute the treatments of choice. Deeper spots are to be de- 
 stroyed exclusively by electrolysis. Where there is the slightest 
 indication of extension or malignant change, early wide excision is 
 the only recourse. Radiotherapy and radium are not to be recom- 
 mended. 
 
 [Any method of treatment which does not insure the removal or 
 destruction of every single nevus-cell must be condemned. The 
 cells left in the scars produced by electrolysis or other methods of 
 cauterization are subject to great irritation from the strain of the 
 scar-tissue, and the methods in question necessarily involve the 
 risk of leaving a few cells intact. In practice no harm results in 
 the majority of cases; but I have seen three cases of cancer devel- 
 oping in nevi treated by electrolysis or C0 2 -snow. A pigmented 
 nevus should be left in peace or else radically, surgically, removed.] 
 
 2. Tuberous Non-vascular Nevi. — These are not simply spots 
 but genuine neoplasms of variable dimensions. 
 
 (a) Soft verrucose nevi (soft warts, cellular nevi). — This name is 
 applied to elevations of the size of a hemp-seed to that of an almond, 
 more or less prominent, sometimes slightly constricted at their base; 
 the surface is smooth or grained, sometimes hairy; the color is pink, 
 yellowish or dusky. Soft warts may be congenital, but appear more 
 frequently during childhood, increasing in size with the approach 
 of old age. They are especially common on the face, the neck, the 
 thorax and in the neighborhood of the external genitals. 
 
 Their chief importance lies in their possible transformation into 
 cancer when they are exposed to repeated irritation or unskilful 
 cauterizations. 
 
 Histological examination shows that these nevi consist of an 
 infiltration of the cutis by round or polyhedric cells with a large 
 nucleus, abundant protoplasm, distinctly epithelioid, solitary or 
 arranged in nests, columns or strands, representing the nevus cells, 
 which are sometimes pigmented. Virchow interpreted these 
 cells as young connective-tissue cells; Demieville, as endothelial 
 cells; Unna showed that they are epithelial and derived from the 
 
NEVI 667 
 
 rete mucosum of the epidermis through proliferation and strangu- 
 lation of the interpapillary processes. This statement has been 
 verified by numerous authors and I too have been able to confirm 
 it. The epidermis itself is often found to contain nests or clusters 
 of pigmented or non-pigmented nevus cells (Fig. 185). Hence the 
 malignant tumors which arise from these soft warts through prolifer- 
 ation of the nevus cells can no longer be regarded as sarcomas of 
 connective-tissue origin, but rather as epitheliomas of a special 
 kind, nevo-carcinomata. 
 
 (b) Nevi Molluscum. — These are more flabby formations than the 
 soft warts, with a thin epidermis and a wrinkled surface. These 
 mollusca may be flattened and spread out, yielding the sensation 
 of a depression in the cutis on palpation; or they may be slightly 
 prominent, like lipomas ; more frequently they are pedunculated and 
 are then called molluscum pendulum. 
 
 The latter, which are very common, develop in the period of 
 adolescence or sometimes in large numbers in the forties; they are 
 chiefly situated on the neck, the back, the eyelids and around the 
 genital regions. Their size varies from that of a pin-head to a pea, 
 often reaching that of a raisin, berry or a small pear. [Crops of these 
 small pendulous fibromata, 50 to 100 or more in number, some- 
 times develop in women on the face, neck and torso, during the 
 later months of pregnancy, disappearing for the greater part in the 
 course of a year or two, constituting therefore a form of dermatosis 
 of pregnancy. ] 
 
 Fibroma molluscum; some voluminous nevi molluscum form 
 large flabby tumors, either not very prominent and lobulated or on 
 the contrary hanging down in the shape of a wallet, sometimes 
 reaching the dimensions of an orange or a child's head. 
 
 When they enclose hard nodular strands, which usually are 
 thickened nerves, they bear the name of plexiform neuromas. 
 
 In a considerable number of cases, the large number of nevi 
 molluscum or the mere presence of fibroma molluscum may suggest 
 the existence of an incomplete or abortive form of Recklinghausen's 
 disease which will be described further on. 
 
 All these nevi molluscum are histologically made up of a special 
 fibromatous tissue, with fine connective-tissue fibers and very 
 numerous young cells, without an elastic plexus. They practically 
 never undergo a cancerous change [but myxomatous degeneration 
 is frequent]. 
 
 (c) Hard or Hyperkeratotic Verrucous Nevi. — These have been 
 described with the circumscribed keratoses (p. 206). Their structure 
 is that of generalized hyperkeratosis; nevus cells are only rarely 
 present. 
 
 I repeat that they may assume an arrangement as linear streaks, 
 
668 TUMORS OF THE SKIN 
 
 or ;is osteo-follicular keratoses (p. 4(K>); and finally, the appearance 
 known as porokeratosis, when they affect the palmar or plantar 
 regions (p. 216). 
 (d) Hairy Nevi (New, Pilosi). — An exaggerated development 
 
 of the hairs, their follicles and their sebaceous glands, may be 
 encountered in the pigmentary nevi and in all the varieties of non- 
 vascular tuberous nevi. These hairs are often thick or enormous, 
 dark and curly, more or less abundant; giant comedos, sebaceous 
 cysts or small horny cysts may also be seen. Hypertrichosis in 
 spots or on larger surfaces, which may constitute a partial furry 
 coat, must be included with the hairy nevi (p. 405). 
 
 Treatment. — What has been stated about the treatment of lentigo 
 is strictly true in all respects for the soft warts. Electrolysis is by 
 far the best mode of intervention and yields the best esthetic results. 
 The treatment of the other varieties is optional; according to the 
 cases, they may be dispersed or removed with the galvano-cautery, 
 the bistoury, carbonic acid snow, etc. [I have already stated my 
 objections to any except radical treatment for these conditions.] 
 
 Neurofibromatosis or Recklinghausen's Disease. — This is a typical 
 developmental and, strictly speaking, nevic disease, sometimes 
 familial, having its principal manifestations in the skin and the 
 hypoderm (Fig. 188). 
 
 Neurofibromatosis is characterized by four sets of symptoms: 
 ( 1 ) Pigmentations, under the form of liver spots, lenticular spots and 
 regional or diffuse melanoderma; (2) cutaneous tumors, scattered 
 in one region or over almost the entire body, being nevi molluscum 
 of all varieties and dimensions; they often begin in the hypoderm, 
 where they may be recognized by a bluish spot and by their con- 
 sistence; they protrude after the fashion of a hernia through the 
 cutis and later on become pedunculated; (3) tumors of nerves, 
 assuming the form of hard, rounded or spindle-shaped, sometimes 
 moniliform nodes, perceptible along the course of the subcutaneous 
 nerve-filaments of the forearm, the flanks, the forehead, the neck, 
 or the thighs; they are due to the development around the nerve- 
 sheaths and especially in the interior of the latter, of a tissue like 
 that of fibroma molluscum; (4) mental disturbances, consisting of a 
 general intellectual deterioration or loss of emotional control. |In 
 my experience mental disturbances are extremely rare.] 
 
 Numerous incomplete cases occur, in which either the tumors of 
 the nerves or the pigmentations, etc., are absent. The pigmen- 
 tations are of such characteristic appearance, through the associa- 
 tion of the three forms mentioned above, that when they are the 
 only symptoms present, a diagnosis of Recklinghausen's disease is 
 sometimes justified. 
 
 In other cases, some of the tumors assume a considerable size 
 
EPITHELIAL TUMORS 
 
 0(i9 
 
 and are then designated as major tumors. They present the appear- 
 ance either of fibroma molluscum or of plexiform neuromata, or 
 even of dermatolyses (p. 372). 
 
 Fig. 188. — Neurofibroma. Vor^ Recklinghausen's disease. (Ormsby. 
 
 Neurofibromatosis appears in the course of childhood or adoles- 
 cence, develops in successive instalments and then persists indef- 
 initely. Distinct retrogressions have, however, occurred in my 
 experience. 
 
 EPITHELIAL TUMORS 
 
 The tumors derived from the epidermis or its adnexa, hair follicles 
 and glands, consist in part of simple tissue hyperplasias, in part of 
 
670 TUMORS OF THE SKIN 
 
 hyperplasias with metaplasia or metatypism, i. c, a more or less 
 pronounced modification of the normal cell type. The statement is 
 justified only in a very general way that the former follow a usually 
 benign course, whereas the latter are as a rule of malignant character. 
 
 As a matter of fact, the conditions governing the malignancy of 
 tumors, their tendency to indefinite invasion and generalization, 
 are entirely unknown at the present time. 
 
 Papillomata. — The attempt has been made to group under this 
 term all outgrowths resulting from a proliferative hypertrophy of 
 the epidermis (p. 237). In reality, the term papilloma is appli- 
 cable only to an objective appearance. To state that a cutaneous 
 or mucous lesion is a papilloma is no more equivalent to a diagnosis 
 than it would be to describe a disease as a papule or a bulla, but it 
 simply describes an existing dermatological lesion. This derma- 
 tological form, to which Chapter XII is devoted, may manifest 
 itself under a great variety of conditions. 
 
 Common and flat warts, as well as venereal warts, are almost 
 certainly of infectious origin. The same is true for a considerable 
 number of the other proliferative dermatoses. Verrucous nevi are 
 papillomas resulting from a local malformation. 
 
 In the angiokeratomas (p. fi95) the verrucous condition is sec- 
 ondary to the angiomatous newformation. 
 
 It is an important and noteworthy fact that certain epitheliomas 
 are papillary or begin with a proliferative stage of papillomatous 
 appearance. 
 
 Cysts. — Cysts are neoplasms of a special variety and result, not 
 from an abnormal multiplication of living constituents, but from an 
 accumulation of inert secretory products in an epithelial pocket, 
 lined with a connective-tissue membrane; accordingly, they repre- 
 sent retention tumors. A distinction is made between two classes: 
 
 A. Epidermic and Sebaceous Cysts. — Their size varies from that 
 of a millet-seed to that of a hen's egg; they are intradermic or 
 hypodermic. Their consistence may be hard and elastic, or flabby, 
 or even fluctuating. The skin which covers them may be raised or 
 stretched, but usually retains its normal color; it becomes red- 
 dened in case of inflammation. 
 
 The contents of these cysts are opaque and pasty, made up for 
 the most part of more or less perfectly keratinized epidermic cells, 
 derived from their internal lining, which is epidermic; they also 
 contain fat, a direct product of the developing epidermic cells; 
 fatty acid crystals, soaps, cholesterol and sometimes particles of 
 lime salts. According to its appearance, the contents are described 
 as meliceric, steatomatous, cholesteatomatous, or oily. Suppuration 
 of the cysts caused by infection through pyococci, may lead to a 
 cure. 
 
EPITHELIAL TUMORS 671 
 
 There are five varieties to be described: 
 
 1. Follicular cysts and sebaceous cysts, generally resulting from a 
 dilatation of the pilo-sebaceous canal. Their first stage is represented 
 by comedo; when more advanced they form little yellowish-white 
 elevations which are superficial, umbilicated, pasty cysts that may 
 be emptied by expression. 
 
 2. Dermoid Cysts. — These are derived from an epidermic inclusion 
 in the region of certain embryonic clefts and are consequently 
 situated especially at the outer end of the eyebrows, in the neighbor- 
 hood of the orbit, on the neck, on the perineal raphe, the scrotum, 
 etc. They may contain hair follicles, hairs, sebaceous glands, etc. 
 
 3. Wens. — These are sebaceo-epidermic cysts, frequently multiple, 
 met with only on the scalp and on the scrotum and appearing only 
 in adult or aged individuals; they are deep and present neither an 
 umbilication nor an orifice. In my opinion, wens are derived from 
 a congenital malformation of folliculo-glandular epidermic buds 
 and should be interpreted as a variety of nevi; constituting cystic 
 follicular adenomatous nevi. 
 
 4. Traumatic Epidermic Cysts. — These are hard, round, painless 
 tumors, which are encountered only on the palmar aspect of the 
 hands and fingers. These cysts seem to result, according to the 
 explanation offered by Gross of Nancy, from a deep implantation of 
 a shred of epidermis, under the influence of a traumatism. They 
 are observed especially in laborers and require months and weeks 
 for their development. 
 
 5. Milium. — The name of milium, or grutum, is applied to white, 
 beady granules the size of a pin-head, which are small epidermic, 
 intra-epidermic or intra-dermic cysts. They are observed as a 
 primary manifestation especially on the upper two-thirds of the face 
 and on the genital organs of both sexes; or secondarily upon cica- 
 trices of no matter what origin ; or as a sequel of bullous affections, 
 especially congenital pemphigus with epidermic cysts (p. 191). 
 
 Histology shows them to result from the dilatation either of 
 sudoriparous canals or hair follicles. Primary milium is a sort of 
 cystic nevus; the milium of cicatrices is a retention-tumor. 
 
 The treatment of all these epidermic cysts, if any is required, con- 
 sists in their removal with the bistoury when they are large or with 
 the curette in the case of milium. Wens may also be treated by 
 injecting into their interior a few drops of pure ether, or ether with 
 bichloride of mercury, or a zinc chloride solution; this injection to 
 be several times repeated. At the time of the spontaneous elimina- 
 tion of the cyst, which takes place at the end of eight or ten days, 
 attention must be given to the thorough extraction of the entire 
 epidermic shell. 
 
(172 Tl MORS OF THE SKIN 
 
 B. Serous Cysts. Aside from the hygromas, the branchial cysts 
 of the neck and of cysticercus cellnlosa which are not cysts of 
 epidermic origin, this class comprises only a single type: 
 
 Hidrocy stoma. Hidrocystoma was pointed out by A. Robinson 
 in 1884 and 1893 as a tense, firm, translucid elevation, from which a 
 watery fluid is discharged on puncture; it is the size .of a pin-head 
 ni- a pea and develops in large numbers on the face, chiefly in 
 middle-aged women who are exposed to the heat of stoves, etc. 
 Hidrocystoma has a tendency to disappear in the winter, reappear- 
 ing in the spring. The little tumor consists of a dilatation of a 
 sudoriparous canal and is in my opinion of nevic character, there- 
 fore constituting cystic sudoriparous adenomata. Needless to say, 
 they have nothing in common with dysidrosis and sudamina. 
 
 Adenomata. — The name of adenoma is at present applied to 
 benign epithelial newformations, of glandular origin, whose con- 
 stituents more or less accurately reproduce the texture of the 
 glands from which they are derived. 
 
 The adenomas of the skin are subdivided into sebaceous adenoma 
 and sudoriparous adenoma or hidradenoma. All appear to have a 
 congenital malformation for their origin and the name of adenoma- 
 tous new, is eminently adapted to them. 
 
 Adenoma Sebaceum. — The most interesting form is represented 
 by the .symmetrical sebaceous adenomas of the face. They appear 
 under the aspect of innumerable small tumors, the size of a millet- 
 seed to a large pea, occupying the nasogenial grooves and their 
 neighborhood, the root of the nose and the forehead, the chin, some- 
 times the vicinity of the auditory meatus, the scalp, etc. (Fig. 189). 
 These adenomas, which are rarely congenital, appear in late child- 
 hood, gradually increasing and persisting indefinitely. A white 
 variety, Balzer type, is known, in which the sebaceous glands under- 
 go an atypical proliferation; a red and soft variety, Pringle type, 
 with glandular and vascular hyperplasia; and a hard variety, 
 Hallopeau-Leredde type, in which I was able to demonstrate the 
 predominance of fibrous tissue, so that this condition should rather 
 be described as a fibro-vascular nevus. [Adenoma sebaceum is 
 often associated with other congenital malformations. Several 
 cases of association with multiple subcutaneous fibromas, teratoma 
 of a kidney and mental disorders have been recorded.] 
 
 Nonsymmetrical sebaceous adenomas are seen in aged persons 
 or adults, scattered in variable number especially on the scalp, the 
 face, or the back, from the size of a lentil to that of a nut or larger. 
 
 The heterotopic sebaceous (/lauds of the mucosa' may be considered 
 with the adenomata; they arc not infrequently seen in the mouth, 
 on the internal aspect of the lips and cheeks. They have the appear- 
 ance of very small, hardly protuberant spots, the size of a pin-point 
 
EPITHELIAL TUMORS 
 
 673 
 
 or head, of a golden yellow or cream yellow color, solitary or in 
 abundant crops. They do not develop until after puberty. In 
 America this anomaly is described under the name of Fordyce's 
 disease. It is of interest only on account of the diagnostic errors 
 to which it may give rise, in the differentiation from buccal lichen 
 planus, etc. 
 
 Fig. 189. — -Symmetrical sebaceous adenoma of the face, Balzer type. 
 
 Hidradenoma. — These small neoplasms — also designated as syringo- 
 cystadenoma, etc. — have two seats of predilection : 
 
 1. On the anterior surface of the thorax and the neck, where we 
 described them with Jacquet, under the name of hidradenomes 
 eruptifs; they are rare, appearing between the age of ten and 
 twenty years, as numerous solid, often oval protuberances of a 
 pale pink color, resembling syphilitic papules, but not scaly; they 
 
674 
 
 T l MORS OF THE SKIS 
 
 lasl indefinitely or may disappear. Lesions of the same nature may 
 also be found scattered over the abdomen, on the arms and on the 
 face. 
 
 2. Hidradenomas of the lower eyelids arc certainly much more 
 common. They are met with especially in adult or aged women. 
 They arc of the color of the skin, the size of a pin-head (Fig. 190) 
 and must not be confused with xanthelasma of the eyelids. 
 
 In both cases the structure of the hidradenomas is characteristic; 
 the corium is found to contain cylindrical and branched epithelial 
 strands, dilated here and there into very minute cysts. They are 
 practically unanimously referred at present to an abnormal prolif- 
 eration of rudimentary undeveloped sweat-glands. The interpre- 
 tation implied by the name of lymphangioma tuberosum multiplex, 
 given by Kaposi to these small neoplasms, is obviously erroneous. 
 
 Fig. 190. — Hydradenoma ot the eyelids. 
 
 The treatment of adenomas in general consists in ablation with 
 the bistoury when they are very large. Small adenomas, if the 
 patient desires their removal, should be treated with electrolytic 
 punctures, or when this is not practicable with the curette and the 
 galvano-eautery. 
 
 Molluscum Contagiosum. — This designation, due to BatCman — 
 and preferable to the names of acne varioliformis, Bazin; molluscum 
 sebaceum, Hebra; epithelioma contagiosum, Neisser, etc. — is applied 
 to peculiar small epithelial tumors which are neither adenomas nor 
 epitheliomas. 
 
 Molluscum contagiosum presents itself as small hemispherical 
 prominent elevations of a milk-white, pearly or pink color, their 
 i ssential feature being that they are umbilicated on their crest. 
 Their size varies from that of a pin-point to that of a very large pea; 
 they may become conglomerated into a tumor as large as an almond, 
 which has a tendency to become pedunculated. By compression 
 between two fingers a creamy or pasty mass can be scmeezed out 
 
EPITHELIAL TUMORS 
 
 675 
 
 of the umbilicus, consisting under the microscope of horny cells and 
 of refractive ovoid corpuscles, the so-called molluscum bodies. 
 
 The tumors, which vary greatly in number from a few units to 
 several hundreds, are of variable dimensions and appear insidiously, 
 in successive crops. They are scattered on the face, especially on 
 the eyelids, the neck, the genitals and their neighborhood, but may 
 be found anywhere (Fig. 191). Left untreated they persist indefi- 
 nitely, without any subjective symptom, multiplying through auto- 
 contagion; some of the tumors may become inflamed, suppurate 
 and disappear. 
 
 Fig. 191. — Molluscum contagiosum of the region of the knee. 
 
 Molluscum is observed [most frequently] in children and in youth- 
 ful individuals of both sexes with a delicate skin. 
 
 Its contagiousness is undeniable; Vidal, Retzius, Hanau and 
 others have successfully inoculated them; the incubation takes 
 several months. [Wile and Kingery have reproduced them by 
 intracutaneous injection of a filtrate (Berkefeld) of macerated 
 molluscum turn or. J 
 
 Histology shows molluscum contagiosum to be formed by fairly 
 regular pyriform epidermic lobes with their small extremity turned 
 toward the umbilication. Notwithstanding the gross analogy of 
 their configuration, it is an established fact that these tumors never 
 develop from sebaceous glands. The Malpighian cells of the 
 lobules in proportion as they are pushed back toward the umbilicus, 
 undergo in part a keratinization with eleidine, while others undergo 
 special changes transforming them into molluscum bodies of ovoid 
 shape, which present the reactions of colloid or keratoid substances. 
 
676 TUMORS OF THE SKIN 
 
 Their special interest lies in the misinterpretation of these bodies 
 as psorospermia or coecidia, a view which has been proved false. 
 
 The condition actually is a special dyskeratosis, related to that 
 observed in psorospermosis follicularis and Bowen's disease. The 
 corpuscles are not the carriers of the contagium; Juliusberg and 
 Borrel have shown that the virus of molluscum contagiosum is 
 filtrable. 
 
 The best treatment is extirpation with the curette, which is easy 
 and leaves no cicatrices. [Expression between two thumb-nails is 
 simple and effective.] Into the small tumors which have first been 
 emptied by expression, the end of a pointed match dipped in tinc- 
 ture of iodine may be introduced. When the tumors are small and 
 very numerous, applications of iodine tincture, soft soap, or cam- 
 phorated alcohol may prove sufficient. 
 
 Epitheliomata. — Cutaneous epitheliomas are tumors resulting from 
 an atypical proliferation of the epidermis and of its adnexa. They 
 have also been designated by the names of epithelial cancers, 
 cancroids, formerly as polyadenomas, erosive ulcers, noli me tangere; 
 abroad, especially in Germany, they are all grouped under the head- 
 ing of carcinomata, whereas in France the latter term is reserved 
 for the malignant and invasive cancers. 
 
 In the following brief account I shall include the epitheliomas of 
 the buccal cavity as well as those of the external genital organs, etc., 
 which are equally of dermatological interest. 
 
 Among the highly multiple clinical forms of epithelioma, some 
 possess extreme malignancy while others on the contrary are abso- 
 lutely benign. These will have to be very carefully differentiated. 
 It must be emphasized, however, that even epitheliomas of a 
 malignant character begin as a rule as an apparently insignificant 
 lesion, readily amenable to early treatment. There is no knowledge 
 of greater practical importance for the physician than familiarity 
 with the mode of onset of cancers; when properly forewarned he 
 will know how to caution his patients against the possible gravity 
 of a trifling "sore" and to rid them of it in time. 
 
 Clinical Forms. — The attempts which have been made to find in 
 the histological structure of the various forms of epitheliomas an 
 explanation of their widely divergent course have been only partially 
 successful. The classification which I proposed at the International 
 Congress in 1904, although based upon the histological structure, 
 takes largely into account the objective features and the develop- 
 mental tendencies of each kind, namely those characteristics which 
 possess the greatest practical importance. This classification is 
 here repeated. 
 
 1. Lobular or Spinocellular Epithelioma. — In this first class, the 
 neoplastic masses are usually arranged in elongated and enlarged 
 
EPITHELIAL TUMORS 677 
 
 interpapillary buds, or in lobules and in wide strands; they are 
 made up essentially of Malpighian, prickle or spinous cells; these 
 cells undergo the usual epidermic evolution, with formation of 
 keratohyaline, becoming keratinized into horny cells and often into 
 epidermic pearls. This class is subdivided into two types: 
 
 A. Superficial Proliferative Type or Papillary Epithelioma. — This 
 type comprises: 
 
 (a) Homy papillary epithelioma, which develops in healthy skin, 
 or not infrequently on a senile keratosis. It is encountered in all 
 regions but especially in the face, on the lips, the neck, the back 
 and on the dorsal aspect of the extremities. It begins as a verrucous 
 elevation and persists a long time in this condition; then, almost 
 invariably in connection with traumatism, it spreads as a protuber- 
 ant disk bordered by a raised and hem-like margin, the center being 
 studded with villous elevations covered by adherent horny crusts. 
 The glands remain intact for a long time. This epithelioma bleeds 
 readily, may ulcerate and finally leads to cancroid. 
 
 (b) Cornu cutaneum — that is to say, senile horny excrescences, 
 for there exists a juvenile form belonging to the class of hyper- 
 keratotic nevi (p. 206) — is a papillary epithelioma with exuberant 
 hyperkeratosis. These horns are of extremely variable size and some- 
 times resemble a ram's horn from every point of view, including 
 the curvature. They develop in healthy skin or on senile keratosis, 
 chiefly in the face, on the scalp, the glans and the prepuce. Their 
 base may be surrounded by a rose-colored border. Their growth is 
 usually very slow; when they fall out or are removed, they will 
 grow again. The histological lesions are those of papillary epithe- 
 lioma, more or less pronounced; the horn itself is formed by agglu- 
 tinated cellular columns; it is softer in its center. These growths 
 may develop into cancroid and this contingency must be kept in 
 mind for the treatment. 
 
 (c) Naked papillary epithelioma, without a horny covering, is met 
 with on the lips, the buccal mucosa, the glans and the vulva; its 
 surface is red, velvety and glistening. It follows a slow and for a 
 long time benign course, but may become ulcerated and pass into 
 cancroid. 
 
 It is necessary to guard against confusion of this variety of 
 epithelioma with the proliferative syphilides, with tuberculous lupus 
 of the mucous membranes, etc. Examination by biopsy shows a 
 marked increase of the interpapillary buds in width and in height, 
 with a very moderate cellular infiltration in the upper portion of the 
 cutis. 
 
 B. Deep Type or Cancroid Epithelioma. — This is the penetrating, 
 infective, malignant form of epithelioma of the skin and the mucous 
 membranes with a Malpighian lining. 
 
67 
 
 TUMORS OF THE SKIN 
 
 It develops especially at the orifices; on the lips, on the tongue 
 (Fig. 71 ) and on the floor of the mouth, where it appears as a com- 
 plication of leukoplakia, it is known as smokers' cancer; it is not 
 uncommon at the amis and on the penis, but may occur anywhere, 
 notably on scar tissue and on lupus vulgaris. 
 
 When cancroid does not result from the malignant evolution of a 
 papillary epithelioma, but originates in healthy skin, it is at first 
 a grayish tubercle covered with a scale or a small crust. Under the 
 
 . 
 
 Fig. 192. — Horny lobular epithelioma, spinocellular epithelioma, or cancroid, 
 developing on leukoplakia of the tongue. A, leukoplakia; B, raised border; C, 
 erosion; D, lobulated masses; E, epidermic pearl; F, bloodvessel and plasma-cell 
 infiltration; G, nerve; H, muscle tissue. X 38. 
 
 influence of scratching or traumatisms, it increases in extent and in 
 depth; its crest becomes reddened and ulcerated. Promptly a 
 tumor forms, the size of a cherry-pit or a hazel-nut, hard, imbedded 
 in the skin as well as protuberant. Its borders are raised and swollen 
 and usually more or less hyperkeratotic. On the central area appears 
 first an erosion, then a perpendicular ulceration, which is irregular, 
 fissured, grayish and bleeds easily. 
 
 Yellowish granules or filaments, known as "pearls" composed of 
 horny cells and epidermic globules, may be visible and can some- 
 
EPITHELIAL TUMORS 679 
 
 times be squeezed out. There may be pain on pressure and move- 
 ment. The glands rapidly become enlarged. I have described 
 elsewhere how this cancer develops on leukoplasic mucous mem- 
 branes (p. 221). 
 
 Histologically, the classical structure of lobulated horny pavement- 
 cell epithelioma is seen (Fig. 192). The large cylinders which pene- 
 trate into the depth of the tissues, where they form an irregular 
 lobulated network with large meshes, are apparently derived from 
 interpapillary buds or from pilo-sebaceous follicles. They almost 
 invariably enclose collections of lamellar cells, concentrically 
 arranged after the manner of an onion, known as epidermic pearls; 
 more or less numerous dyskeratotic cells (p. 230) are regularly 
 demonstrable. The stroma has a variable structure, but is rather 
 scanty as a rule. At the circumference, plasmocytes are abundantly 
 present. Neoplastic strands having the same structure as the original 
 tumor may be found in the lymph channels. 
 
 The tumor ultimately increases in depth, the ulcer becomes 
 gangrenous, the infected cancerous glands may open externally. 
 Death occurs in marasmus or as the result of hemorrhage. 
 Generalization in the viscera is rare. 
 
 The calcified epithelioma of Malherbe is a rare and very peculiar 
 variety of spinocellular epithelioma in which the epithelial lobes 
 undergo a total infiltration with lime-salts. It develops as a rule 
 at the expense of old sebaceous cysts, wens or dermoid cysts and 
 consists of masses of stony hardness which grow very slowly. Unless 
 it undergoes transformation into ordinary cancroid, it follows a 
 benign course. 
 
 2. Tubular or Baso-cellular Epitheliomata. — In this group the neo- 
 plastic masses assume a very variable arrangement, as narrow 
 irregularly branching strands, in tubules, in leaf-like lobules with 
 tapering processes, or as a network, etc. (Fig. 193) ; their continuity 
 with the covering epidermis or with the pilo-sebaceous follicles is 
 often demonstrable. In the center of these masses, small foci of 
 mucous or colloid degeneration are sometimes seen which must not 
 be mistaken for epidermic pearls. The neoplasm is composed 
 exclusively of small oval or spindle-shaped epithelial cells, taking a 
 deep stain, with few or no connecting filaments; briefly, presenting 
 the appearance of the basal cells of the epidermis. The stroma is 
 variable, often fibrous and sometimes mucous or embryonic. 
 
 This kind of epithelioma is common in all persons of advanced 
 years and in the aged, especially in connection with senile keratosis. 
 Its seat of election is on the upper two-thirds of the face, where 
 four-fifths of all epitheliomas are tubular; it is also encountered, 
 although more rarely, on the lips, the tongue, in the pharynx, on the 
 chest, the genital organs, etc. 
 
6S0 TUMORS OF THE SKIN 
 
 The onset is usually in the form of an insignificant papule, which 
 originates in healthy skin or on a patch of senile keratosis; there is 
 a smooth, yellowish or grayish, pearly elevation, firm to the touch, 
 the size of a pin-head or a lentil. It may resemble a Hat wart, a 
 cellular nevus, a sebaceous or sudoriparous adenoma. A vague 
 tingling sensation causes scratching; the papule becomes excoriated 
 and covered with a constantly renewed crust or it may remain 
 ulcerated. Its growth is very slow for a few months or even for 
 several years, until quite suddenly it becomes more rapid. 
 
 Fig. 193. — Tubular epithelioma (baso-cellular) of the cheek, with the clinical 
 features of flat cicatricial epithelioma. Note the branched epithelial strands, made 
 up of basal cells; their continuity with the surface epidermis and with a bud tra- 
 versed by a sweat-channel ; the erosion covered with a crust on the right side in the 
 illustration; on the lefl part of a mass which encloses a focus of mucoid degeneration. 
 The neoplasm, which causesno protuberance, occupies the entire cutis down to the 
 level of t he sudoriparous glomeruli and the vessels of the subcutaneous plexus. X 38. 
 
 Although very readily curable in its incipient stages, by man}' 
 kinds of treatment, this form of skin cancer nevertheless possesses 
 extreme malignancy; it may become mutilating and incurable 
 when it remains unrecognized, when intervention comes too late 
 or the treatment is inappropriate. Its malignancy is purely local, 
 however, glandular enlargement and metastases being invariably 
 absent. 
 
EPITHELIAL TUMORS 
 
 681 
 
 Although constituting a single histological and nosological species, 
 basocellular epithelioma tends to take an extremely variably course, 
 so that it presents itself clinically under a highly variegated aspect, 
 as tubercles surrounding a cicatrix, as an eroded surface, an ulcer 
 or a tumor; these configurations may moreover coexist or follow 
 one another. The following types may be described. 
 
 (a) Flat cicatricial epithelioma while spreading becomes depressed 
 at its center, which undergoes sclerotic atrophy. After a certain, 
 sometimes very protracted length of time, it presents the appear- 
 ance of a rounded or rather irregular cicatricial patch, bordered by 
 a seam or chaplet of small grayish, scaly or smooth, more or less 
 translucid elevations, owing to which it is also known as pearly 
 epithelioma. Not infrequently, rather shallow, flat or granulating, 
 slightly bleeding ulcerations form on the borders and gradually 
 invade the vicinity (Fig. 194). The ulcer, bordered or not with 
 pearly granules, often heals on one side while it extends on the other, 
 
 Fig. 194. — Cicatricial flat epithelioma of the temple. Behind, on the side of the 
 scalp and ear, a cicatricial surface is seen, interspersed and bordered with pearly- 
 elevations; in front, on the side of the eye, there is a serpiginous ulceration. 
 
 destroying the eyelids, the eyeball, the cartilages of the nose and 
 even the bones; it gradually causes enormous and frightful muti- 
 lations. I have observed cases which had lasted for twenty and 
 thirty years. The tendency to recurrences, after an apparent cure, 
 is extremely pronounced. 
 
 (b) Pagetoid epithelioma is far from common, but important to 
 know on account of the diagnostic errors to which it is subject; it 
 presents a pinkish surface, distinctly circumscribed by rounded 
 borders marked by a filiform margin, its area being spattered with 
 small scales and crusts, resting upon an atrophic cutis. Its growth 
 is extremely slow. I have observed it only on the face and on the 
 back of aged individuals. It might be confused with senile keratosis, 
 lupus erythematodes, psoriasis and especially with Paget's disease, 
 or with the atrophic spots of Bowen's disease. Biopsy reveals 
 more or less widely separated proliferations of basocellular epithe- 
 lioma. 
 
G82 TUMORS OF THE SKIN 
 
 (c) Rodent ulcer — or ulcus rodens — is characterized by a shallow 
 and serpiginous ulceration, with a slightly indurated base, without a 
 pearly elevation and a very slow course. Only very fine epithelio- 
 matous tubules are seen in histological sections. 
 
 ill) Epithelioma terebrans may be the outcome of one of the 
 preceding varieties or it may set in primarily; the newformation 
 and ulceration advance in depth rather than superficially; craters 
 and often very deep oozing cavities appear, with a red granular 
 surface, surrounded by a limited induration (Fig. 95). Although 
 very destructive, mutilating and painful, this form likewise possesses 
 a merely local malignancy; the glands generally remain intact as 
 well as the general health. Many months and years may pass before 
 the patient succumbs to hemorrhage or complications of one kind 
 or another. 
 
 (e) Proliferative tubular epithelioma, which is less common, gives 
 rise on the contrary to a genuine tumor, in the form of an eroded and 
 puckered macaroon-shaped elevation, or a protuberance the size of 
 a pea, a hazel-nut, or rarely a large chestnut, sometimes peduncu- 
 lated, of firm consistence, with an ulcerated and bleeding or crusted 
 surface. This proliferation is sometimes seen to develop rather 
 rapidly at some point of a slowly growing flat epithelioma. 
 
 (/) Cylindroma of Billroth and Malassez, is really an atypical 
 variety of the preceding form in which the stroma undergoes a 
 mucous and hyaline degeneration; there is a formation of trans- 
 lucid cylinders and clear ovoid proliferations which invade and 
 push back the epithelial masses, resulting in peculiar histological 
 appearances which have been variably interpreted, as shown by the 
 numerous denominations of these tumors, such as siphonoma, 
 endothelioma, plexiform sarcoma, angiosarcoma, etc. Cylindro- 
 matous tumors are situated especially on the scalp, in the middle of 
 the face, or in the buccal cavity; they are sometimes voluminous 
 often multiple and rarely undergo ulceration. Their prognosis is 
 the same as that of the other tubular epitheliomata. 
 
 3. Nevo-cellular Epitheliomas or Nevo-carcinomata. — From the 
 purely histological point of view, the cellular nevi themselves are 
 benign nevo-cellular epitheliomas. 
 
 These nevi, whether pigmented or not, verrucous or smooth, 
 hairy or glabrous, are sometimes the starting-point of malignant 
 tumors in adult and aged individuals; it has seemed to me that the 
 face and the [heels and] plantar region of the feet are the two 
 elective foci of this transformation. 
 
 The tumor then is seen to enlarge in size and becomes painful; 
 its circumference is reddened or becomes the seat of a melanotic 
 pigmentation. Early and more or less rapidly invasive ulceration 
 follows. Similar small tumors promptly begin to multiply in the 
 
EPITHELIAL TUMORS 683 
 
 vicinity, then at a distance. In case the primary neoplasm was 
 pigmented, generalization takes place by the appearance either of 
 numerous secondary pigmented or non-pigmented tumors or of 
 extensive localized or metastatic pigmentations, or of a generalized 
 melanosis. The glands are promptly involved in this form, which 
 often possesses great malignancy; metastases in the viscera, notably 
 in the liver and lungs, is of common occurrence. 
 
 The histological structure of these malignant tumors derived 
 from nevi is peculiar (Fig. 195). 
 
 It A. 
 
 Fig. 195. — Histology of a pigmentary nevus (lentigo) and of the incipient nevo- 
 carcinoma. Section from the border of the tumor, c. n. d., nevus cells, pig- 
 mented or clear, in the cutis; c. n. e., pigmented nevus cells in the intra-epidermic 
 tissue ; p, infiltration of plasma cells at the circumference of the tumor ; x, transition 
 zone between the nevus and the nevo-carcinoma; n. c, tissue of the nevo-carcinoma 
 of sarcomatous appearance; k, portion of an epidermic cyst which was contained in 
 the nevus. X 57. 
 
 Their constituents are globular or spindle-shaped, sometimes 
 pigmented, arranged in compact masses, in imperfectly outlined 
 strands or in alveoli; sometimes the appearance is entirely that of a 
 sarcoma. 
 
 For a long time such cases were interpreted as sarcomatous tumors 
 and designated as melanotic sarcoma or melano-sarcoma. The name 
 of nevo-carcinoma, proposed by Unna, who showed the epithelial 
 origin of nevus cells and consequently of the neoplasms derived 
 from them, is much better justified (see my paper on nevo-carcinoma, 
 in Bulletin de V Assoc, f rang, du cancer, November, 1913). 
 
 4. Secondary Carcinoma.— Metastatic epitheliomas are also met 
 with in the skin, although but rarely, derived from operated or 
 
084 TUMORS OF THE SKIN 
 
 non-operated cancers of the breast, or from internal cancers, as 
 the result of neoplastic embolisms in the vessels. 
 
 They are characterized by hard, pinkish, purplish or brownish 
 elevations, the size of a pin-head to that of a hazel-nut; solitary at 
 first, they gradually become confluent in irregular, mammillated 
 surfaces (Velpeau's cancer en cuirasse). They are apt to ulcerate, 
 proliferate and become fungoid. Sometimes an extensive patch or 
 surface of scirrhus cancerous lymphangitis develops, which may 
 resemble a patch of scleroderma. 
 
 The histological characteristic of secondary carcinoma of the 
 skin is that the neoplastic masses, made up of cells suggesting the 
 primary tumor cells, are without connection with the surface or 
 folliculo-glandular epidermis; they are arranged in branching tracts 
 following the vascular and lymphatic channels; later on, alveoli 
 are hollowed out. The dermic stroma presents at the onset prac- 
 tically no indication of any reaction, but subsequently becomes 
 sclerotic and retracted. 
 
 Etiology and Pathogenesis of the Epitheliomata. — We know that 
 cutaneous epitheliomas practically never develop until after the age 
 of forty years and more frequently in males; when they occur in 
 more youthful patients these will be found to have suffered as a 
 rule from a precancerous affection. The part played by heredity 
 is doubtful. 
 
 The cause of the facial localization of the vast majority of epithe- 
 liomata of the skin is not known; undoubtedly it is to a considerable 
 extent because this region is the seat of election of senile degener- 
 ation and leukoplakia; because it is particularly exposed to trauma- 
 tisms, to inoculations of infectious germs, to the influence of atmos- 
 pheric factors and especially of light, which seems to exert a 
 favoring action [and possibly because the complicated planes of 
 embryonic growth in the face afford a ready opportunity for the 
 misplacement of epithelial cells]. 
 
 The direct cause of epithelioma and cancerous tumors in general 
 still remains unknown. 
 
 The parasitic or exogenic theory, although very tempting at first 
 sight, rests on no reliable basis. None of the hitherto described 
 cancer parasites have withstood criticism. The coccidia which were 
 supposed to have been discovered, turned out to be merely forms of 
 cellular degeneration and dyskeratosis. We know that there exists 
 in mice a form of contagious cancer, which is inoculable and can 
 be indefinitely transplanted into animals of the same species, certain 
 breeds of mice being predisposed to it; but the causative agent has 
 never been isolated. There is nothing to justify the statement that 
 human cancers are of infectious origin. Borrel reported in small 
 epitheliomas of the face the usual presence of a demodex, which he 
 believes to be the possible carrier of unknown pathog nic germs (?) 
 
EPITHELIAL TUMORS 
 
 685 
 
 Opposed to this interpretation are the cellular or endogenic 
 theories, which assume aberrant embryonic germs and cellular 
 heterotopia, with Cohnheim and Ribbert, or a loss of balance of the 
 tissue constituents, or their abnormal fertilization, according to 
 Hallion, etc. 
 
 It must be admitted that the conception of precancerous states 
 is rather an argument against the parasitic theory. Perhaps, epi- 
 thelioma is merely the outcome of various processes, sometimes 
 of teratological or dystrophic character; in other cases of ordinary 
 inflammatory or even specific character. 
 
 -Multiple epitheliomatosis of the face on senile keratosis, 
 in the St. Louis Hospital, Paris. 
 
 After a cast 
 
 Precancerous Affections. — This designation is applied to patho- 
 logical conditions which are so frequently the origin of cancers that 
 this coincidence cannot be the effect of a mere accident. 
 
 These affections are of various kinds and have been described in 
 the chapter to which they belong. I shall therefore restrict myself 
 in this paragraph to a general summary. 
 
686 TUMORS OF THE SKIN 
 
 1. Xevi are malformations which lead to nevo-carcinoma. 
 
 2. Various dystrophies are precancerous. 
 
 The term of senile multiple epitheliomatosis (Pig. 196) serves to 
 designate a very common syndrome consisting of the simultaneous 
 or successive development of several epitheliomas at the site of 
 senile keratoses (p. 209) and on a soil of senile degeneration of the 
 skin. These epitheliomas are, as a rule, of tubular type, sometimes 
 papillary or rarely mixed. Presenile dystrophy is followed by similar 
 sequelae (p. 358). 
 
 Xeroderma pigmentosum (p. 355) and up to a certain point the 
 chronic radiodermatitides (p. 454) lead to an analogous picture; in 
 the latter case, the epitheliomas as a rule are horny and papillary, 
 later on cancroid. 
 
 Arsenical cancer is simply a progressive and imperceptible trans- 
 formation of verrucous arsenical keratoses (p. 213) into multiple 
 epitheliomas, usually of a horny papillary type. 
 
 3. Leukoplakia is entitled to special mention among the pre- 
 cancerous affections, as it is the customary although not constant 
 substratum of the lobulated epitheliomas of the mouth, the genital 
 regions and the anus (p. 221). 
 
 4. Epitheliomas of various types likewise develop, although much 
 less commonly, on very different dermatoses, among which must 
 be quoted: lupus vulgaris; cicatrices of any origin, but especially 
 the old cicatrices of burns; the occupational dermatosis of chimney- 
 sweeps, workers with tar and paraffin, coal-heavers; dermoid cysts 
 and wens; ulcers and fistulas, obstinate psoriasis, lupus erythema- 
 todes, etc. 
 
 5. Among the dyskeratoses (p. 230), there are two which evidently 
 represent precancerous affections: In Paget' s disease, the termina- 
 tion in cancer is the rule, sometimes after a very long time, it must 
 be admitted. In Bourn 's disease half of the known cases (three of 
 the six cases published by Bowen and by myself) have led to can- 
 cerous transformation. 
 
 Diagnosis of the Epitheliomas. — The clinical forms are too varied 
 to admit of completeness in this connection. At the onset, the 
 epitheliomas must be distinguished from warts, nevi, etc. Cancroid 
 sometimes resembles syphilitic chancre, or the tuberculo-ulcerative 
 tertiary syphilides, or even tuberculous ulcer. Its neoplastic char- 
 acter must be kept in mind; it is an ulcerated tumor, not an ulcera- 
 tion with an indurated base. Flat cicatricial epithelioma is really 
 easily distinguished from the eczematides, from lupus erythema- 
 todes, from tuberculosis verrucosa; more commonly, the question of 
 a tubercular syphilide may arise; but the principal difficulty which 
 occurs in this connection is to decide whether or not a given spot of 
 keratosis is already epitheliomatous. 
 
EPITHELIAL TUMORS 687 
 
 Under all circumstances, I here repeat the definite and absolute 
 rule which I have previously formulated, to the effect that when 
 there is the least suspicion of epithelioma, recourse should be 
 had to biopsy for the certainty which this method alone can supply, 
 thereby permitting the timely institution of appropriate treatment 
 (c/.,p.222). < 
 
 [The American Society for the Control of Cancer has formulated 
 the rule never to cut into a suspected growth without immediately 
 sealing the cut surfaces by means of the actual cautery; to employ 
 frozen sections for making an immediate diagnosis to be followed by 
 radical operation at the same sitting, if indicated; and under no 
 circumstances to allow more than twenty-four hours to elapse 
 between the biopsy and the operation if the diagnosis is cancer. The 
 risk of dissemination in cutaneous cancers is, however, very small.] 
 
 Prognosis and Treatment. — Although the prognosis depends essen- 
 tially upon the anatomo-clinical type, it is no less true that every 
 epithelioma, no matter what its kind, should be completely removed 
 or entirely destroyed. Internal treatment, arsenic, mercury, etc., is 
 a waste of valuable time; iodide medication is decidedly harmful. 
 Local intervention is what is required. The different forms of epi- 
 theliomata, however, are not amenable to the same methods. 
 
 Spino-cellular Epithelioma. — Papillary epithelioma must be treated 
 by surgical removal, which is easy and provides rapid, reliable 
 results. 
 
 Cancroids demand the earliest possible and very wide surgical 
 excision ; as a rule, the corresponding glands must be removed at the 
 same time. Radiotherapy is not applicable to lobulated epithe- 
 liomata and is certainly harmful in these cases. The few cured cases 
 of lobulated epithelioma through the .T-rays or radium which have 
 been reported, leave some doubt in the mind for lack of sufficient 
 histological demonstration of the spino-cellular character of the 
 tumor. On the contrary, I have repeatedly noted the occurrence 
 of frightful aggravations under the action of this treatment. In 
 the case of absolutely inoperable tumors, however, radiotherapy 
 or radium may be utilized for the relief of the pains. Technical 
 improvements of radium therapy and radiotherapy have on several 
 occasions been promised, which would guarantee reliable cures even 
 of spino-cellular epitheliomas; this progress may indeed be hoped 
 for, but for the present a skeptic attitude is justified. 
 
 Baso-cellular Epithelioma. — Flat cicatricial epithelioma and rodent 
 ulcer are the triumphs of radiotherapy; innumerable cases have thus 
 been permanently cured, with excellent esthetic results. Preference 
 should be accorded to the method of massive doses and filtration 
 through aluminum if necessary, to be repeated, provided the toler- 
 ance of the skin permits (p. 453); the treatment should aim in a 
 
CSS TUMORS OF THE SKIN 
 
 genera] way at keeping the tumor saturated with radiations until 
 after an apparent cure lias been obtained. Should relapses occur, 
 they will yield to renewed treatment. 
 
 In proliferative tubular epithelioma, it is advisable first to excise 
 the larger portion of the tumor, in order to reduce as far as possible 
 the work to be accomplished by the radiations. 
 
 A'-rays and radium institutes are now so numerous in all countries 
 that recourse to them can almost invariably be had. It is useful 
 to know, however, that baso-cellular epithelioma can be cured by 
 other procedures. Surgical operation is not the best, for in the 
 tubular forms it is necessary to pass rather considerably beyond 
 the borders and the floor of the neoplasm, which leads to deplorable 
 mutilations; in case of a recurrence, the additional operations will 
 involve still greater difficulties. Flat epithelioma can be treated 
 with the curette followed by applications of potassium chlorate, or 
 by thermo-cauterization, or by any one of a large number of caustic 
 agents. 
 
 The most convenient and most desirable caustic, which has 
 yielded the largest number of durable and good esthetic results in 
 my experience, is arsenious acid, employed approximately according 
 to the procedure of Czerny and Trunecek. After the epidermised 
 surfaces have been scraped, or freshened or burned with the galvano- 
 cautery, they are painted with a brush dipped in a supersaturated 
 solution of arsenic (arsenious acid, 1 part; water and 90 per cent, 
 alcohol, a a 50 parts); they are then left to dry and are covered with 
 a pledget of cotton. At the end of five to eight days, the crust should 
 be removed; if the subjacent surface is white, it is practically certain 
 that the entire neoplasm has been destroyed; if it is mottled with 
 gray and red, another series of cauterizations should be applied until 
 a perfect result is obtained. This progressive plan of operating 
 provides great security and spares the healthy tissues to the greatest 
 possible degree; the pain is rarely very severe and does not last 
 long. 
 
 [Many dermatologists prefer the acid nitrate of mercury to any 
 other chemical caustic. The tumor is vigorously curetted, the 
 bleeding checked by compression for a few minutes and then the 
 full strength Liq. hydrarg. nitratis is thoroughly applied by means 
 of a cotton swab for several minutes. The surface is then covered 
 with a thick layer of powdered sod. bicarb, firmly pressed down. 
 Xo other dressing need be applied. In ten to fifteen days the crust 
 is shed leaving a clean granulating surface which epidermises with 
 surprising rapidity. The cosmetic result is excellent. | 
 
 Other Epitheliomas. — The cylindromas are treated with the 
 curette, with the bistoury, or with arsenious acid; recurrences are 
 uncommon. 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 689 
 
 New-carcinoma has a gloomy prognosis, on account of its tendency 
 to generalization. It is of the utmost importance to intervene early 
 before dissemination has occurred. Electrolysis constitutes the 
 treatment of choice; it sometimes yields unhoped-for results. I am 
 in the habit of inserting the needle its full length underneath the neo- 
 plasm, at numerous points from 4 to 5 mm. apart and allowing a 
 current of 3 to 6 milliamperes to pass for two or three minutes, 
 using the negative pole. Surgical operation is without advantage. 
 
 In secondary carcinomas, the prognosis depends much more 
 upon the principal tumor and its glandular and visceral generaliza- 
 tion than upon the cutaneous localization. The latter often yield 
 remarkably well to radiotherapy. 
 
 Summarizing, it may be stated that in order to treat cutaneous 
 epithelioma to advantage, it is of importance to make an early and 
 accurate diagnosis, not only of the nature, but of the kind of tumor. 
 For this purpose, examination of tissue by biopsy will [often be 
 indispensable. The treatment must then be adapted to the type of 
 the neoplasm, to its extent and its depth, as well as to its seat and 
 to the general condition of the patient. 
 
 VASCULAR AND CONNECTIVE-TISSUE TUMORS. 
 
 This class comprises very different neoplasms, all of which how- 
 ever originate in the last analysis from tissues derived from that 
 portion of the middle embryonic layer known as the mesenchyma. 
 Among these tumors, some have approximately the structure of 
 normal tissues, as in the case of fibroma, lipoma, myoma, angioma, 
 etc. The constitution of others is such as to result apparently 
 from a local oversupply of elaborated material, perhaps not 
 foreign in quality to the normal organism, but undoubtedly so in 
 quantity: to this order belong xanthoma, urticaria pigmentosa 
 and the tophi of gout, which may be considered as retention 
 tumors. Finally, in a third group, a structure is found suggestive of 
 embryonic or inflammatory tissues; in such cases the course may 
 be benign, as in botryomycoma, or, on the contrary, of extreme 
 malignancy, as in the sarcoma. 
 
 Fibroma. — Aside from fibroma molluscum which has been men- 
 tioned among the nevi, there occur hard dermic or hypodermic 
 fibromata, of very variable size, which may appear at any age; 
 they are sometimes multiple and as a rule do not recur after removal. 
 They are formed by a dense fibrous tissue without elastic network 
 and may undergo fatty, xanthomatous or mucous degeneration, 
 or calcification. Some of these tumors seemed to me to be sarcoids 
 which had become fibrous; others might be regarded as subcutaneous 
 keloids. 
 44 
 
090 
 
 TUMORS OF THE SKIK 
 
 Keloids (xyfy = the claw of a crab) are histologically simply 
 
 hard fibroma s; but they acquire a very special interest through 
 their etiology, their appearance and their clinical course. 
 
 Keloids are preferably observed in children and in youthful 
 individuals; their seat of election is on the chest, on the neck and 
 on the ears; they are less common on the limbs. [Negroes are 
 especially prone to keloid.] 
 
 A distinction has been erroneously attempted between cicatricial 
 keloids and spontaneous keloids, which represent a single variety 
 of tumors. A keloid may develop upon a cicatrix following a burn 
 (Fig. 197), lupus, chancroid, etc., with the result that the scar 
 assumes a more than hypertrophied and deformed appearance 
 (p. 336); or it may follow a slight traumatism, excoriation, vac- 
 cination, perforation of the ear-lobe, the bite of a leech, or the 
 
 Keloid df the neck, on a cicatrix following a burn. 
 
 application of a blister, iodine tincture, etc. ; it may also appear as a 
 sequel of furuncles, syphilides, or acne pustules. In the last-named 
 case, the post-acneic keloids scattered over the thorax and the face, 
 have nothing in common with the affection known as keloid acne 
 of the nape of the neck (p. 391 ). The relative rarity of keloids as 
 sequelpe of wounds in the late war is noteworthy. 
 
 Whatever its starting-point, a keloid begins as a circumscribed, 
 intradermic prominent induration which enlarges in a few weeks or 
 months. It becomes a very hard tumor, with a smooth, level or 
 indented, pinkish or white surface with steep or gently sloping 
 borders, of globular, oval, or frequently elongated shape; it often 
 exceeds the limits of the original lesion and may attain the size of 
 an egg or form a band or elevation thicker than the finger. Xot 
 uncommonly, the borders or the extremities of keloids present 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 691 
 
 fibrous radiations and sometimes bifurcated strands, which suggested 
 the name given to these tumors by Alibert. There may be absolute 
 freedom from pain, or the patient may complain of unpleasant 
 tingling sensations. 
 
 After having increased in size and extent for a few months or 
 years, a keloid may remain stationary or may undergo spontaneous 
 retrogression. Surgical removal is followed by recurrence in case 
 of recent tumors whose development has not been completely 
 arrested. These recurrences are common, not in the entire extent 
 of the surgical cicatrix, but in a portion of the scar, in some of the 
 suture points, but not in all. Moreover, in case of acne for instance, 
 which becomes keloid, some but not all of the pustules undergo this 
 development. From these facts it may be concluded, as I have 
 pointed out, that the appearance of keloids is not connected with a 
 peculiarity of the soil, with a scrofulous or fibroplastic (?) diathesis, 
 as has been claimed, but with a local infection. I am inclined to 
 believe, with T. C. Fox, J. N. Hyde and others, that this infection 
 is of tuberculous character, at any rate in most cases, so that the 
 keloids or at least certain keloids are tuberculides or attentuated 
 tuberculoses. Their structure is that of a very dense fibroma, with 
 mature connective-tissue bundles rich in mast cells (Mantegazza, 
 1897). 
 
 In the treatment of keloids, a host of medicinal agents has 
 been utilized — iodine, arsenic, cod-liver oil, salicylates, thiosina- 
 mine and fibrolysine; locally, plasters, local douches, scarifica- 
 tion, interstitial injections of creosote oil and other substances, 
 electrolysis, etc. I have mentioned the disadvantage of surgical 
 removal, the risk of a larger recurrence with worse deformity. 
 Radiotherapy is more to be recommended. A few sessions will 
 procure considerable improvement; before pushing further, the 
 vitality of the fibrous tissue must be aroused, for example, by 
 negative electrolysis or by local injections, or more practically by 
 deep interrupted scarifications; after which the .r-rays may be 
 resumed and will be found to have acquired an increased activity. 
 I have obtained numerous permanent results by means of this 
 method. 
 
 Lipoma. — The circumscribed lipomas belong to the domain of 
 surgery. 
 
 Multiple subcutaneous lipomas develop in certain individuals, in 
 crops from a few to several thousands in number. Their structure 
 is that of normal adipose tissue; their size varies from that of a pea 
 to a small mandarin orange; their consistence is soft, lobulated 
 and sometimes pseudo-fluctuating; their distribution is often more 
 or less symmetrical. The differential diagnosis from neurofibroma- 
 tosis must be made; this condition probably represents an analogous 
 
692 TUMORS OF THE SKIN 
 
 nevic disease. Fibromas are sometimes partly lipomatous. Cer- 
 tain so-called lipogenic angiomas have a tendency to undergo a 
 transformation into lipoma. 
 
 Myxoma. So-called pure myxoma, soft tumors composed of 
 mucoid connective tissue, are probably partial elephantiasis, as in 
 the case of tumor of the vulva shown in Fig. 116, in which the diag- 
 nosis of myxoma had been made. These neoplasms are preferably 
 situated on the genital organs and on the eyelids. Aside from these 
 false myxomas, there also occur myxo-sarcomas or sarcomas in 
 course of myxomatous degeneration. 
 
 Myoma. — The dermatomyomas or cutaneous leiomyomas — 
 which alone will be discussed in this place — have been classically 
 described by E. Besnier. These tumors, composed of smooth 
 muscle-fibers forming a network of interwoven bundles, are derived 
 either from the erector muscles of the hair-follicles, or from the 
 muscle cells of the vessels. Myomas are rare and are observed in 
 women more often than in men. They may develop at any point, 
 as disseminated or agminated rose-colored elevations, attaining the 
 dimensions of a pea or at most a hazel-nut. They are frequently 
 very tender on pressure and constitute the majority of what has 
 been described as painful tubercles of the skin ; they become the seat 
 of attacks of pain under the influence of local irritation or the action 
 of cold. 
 
 Calcareous Tumors. — In addition to true osteomas, which are 
 exceptional, calcified fibromas, calcified epitheliomas, petrified wens 
 and cysts, as well as phleboliths, the following are known: 
 
 1. The petrous tumors of Poirier, which are calcified fat-lobules 
 the size of a grain of wheat, occurring on the inner aspect of the tibia 
 in aged individuals. 
 
 2. Subcutaneous calcareous granulomas, which begin as a sort of 
 cold abscess with granular or gravelly contents and may multiply 
 until they lead to death with systemic symptoms. This affection, 
 whose lesions closely suggest those of tuberculosis, is undoubtedly 
 infectious. 
 
 3. The subcutaneous calcareous concretions of scleroderma (p. 
 350). 
 
 Colloid Milium. — This very inappropriate term serves to desig- 
 nate small, yellowish, translucid and painless tumors, the size of a pin- 
 head to that of a pea, which may be found scattered or more or less 
 grouped in the face, on the neck and the upper extremities of adults 
 of either sex (p. 359). At first sight they resemble serous cysts; a 
 sort of jelly can be squeezed out of them or they may be enucleated 
 with the curette. Balzer has shown them to be made up of a colloid 
 tissue; degeneration of the dermic tissue into elacine and collacine 
 has been demonstrated. Milian, who recently published a case of 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 693 
 
 colloid milium (1917), interprets the condition as a limited prolifera- 
 tion of bundles of subepidermic connective-tissue fibers, with 
 hyaline degeneration. The foci stain yellow with van Giesen's 
 stain and a dull blue with thionine. With some attention, it is 
 possible to avoid confusion of colloid milium with hidrocystoma, 
 hidradenoma, lupoma or sarcoid, as well as with senile colloid 
 atrophy (p. 357) which, moreover, is spread out in patches and 
 diffuse. The galvanocautery, carbonic acid snow or the curette may 
 be utilized for the treatment. 
 
 Angioma. — Hemangioma.- — The majority of angiomas are vas- 
 cular nevi, the lesion consisting of hypertrophy with ectasis of the 
 veins and, to a less degree, of the capillaries and the arterioles. 
 
 According to their clinical aspect and the date of their appear- 
 ance a distinction is made between several forms: 
 
 (a) Flat angiomas or flat vascular nevi, the port-wine stain of 
 popular parlance, are spots of very variable shape, outline and dimen- 
 sions, punctiform or in very extensive patches. Their color varies 
 at different times from pinkish to bright red or purple. They are 
 especially common on the face and around the natural orifices. 
 On the nape of the neck, at the border of the scalp, they are encoun- 
 tered in nearly 10 per cent, of all persons. [In an examination of 
 several hundred infants less than a week old, I found vascular nevi 
 on the neck below the occipital protuberance in one-third of the 
 cases. Most of these become invisible in the course of time.] They 
 may be seen on the mucous membranes. In epileptics and in feeble- 
 minded persons, patches of vascular nevi may be found on the 
 entire body and on the limbs. [I have recorded a unique case 
 occurring in an otherwise normal man in which the entire integu- 
 ment was covered with vascular nevi of the average size of a dime, 
 so closely placed as to form a kind of network. Histologically 
 there was a deficiency of elastic tissue. Dermographism was present.] 
 These angiomas are, as a rule, congenital. They are sometimes 
 hypertrichotic. 
 
 (b) Tuber ovs angiomas are primary or develop on the basis of 
 the preceding variety. Sometimes they form merely a slightly 
 marked prominence, reducible on pressure, distinctly circum- 
 scribed or with diffuse borders; in other cases, they are voluminous 
 and may cause more or less deformity of the lips, the nose, the eye- 
 lids, the ears or the tongue, up to lending them a monstrous appear- 
 ance. The surface is bright red and granular or dark blue and 
 lobulated, according to the depth of the lesions. Those of the cheek 
 and lips sometimes extend to their mucous surface. They often 
 cease very accurately on the middle line. Aside from their dis- 
 figuring appearance, these tumors may prove troublesome and 
 after traumatism may bleed profusely. 
 
()!)4 TUMORS OF THE SKIS 
 
 The prognosis and the treatment of these angiomas vary. Some 
 of them have a natural tendency to a cure, through lipomatous 
 transformation (lipogenic angioma) or sclerotic change; others 
 simply persist; still others are progressive. In case of a newborn 
 infant suffering from an angioma, its course should accordingly be 
 determined before interfering. In the first two cases, delay is per- 
 missible; in the presence of a progressive angioma, prompt measures 
 are required. 
 
 For a long time the only choice lay between the following pro- 
 cedures: Compression, usually inefficient; actual cauterization or 
 applications of caustic agents, which leave ugly cicatrices; surgical 
 removal, the method of choice when the dimensions and the seat of 
 the angioma permit; scarifications, of advantage in small flat nevi; 
 vaccination, which is rarely applicable; and finally electrolysis. 
 The last-named procedure, the details of which have been well 
 described by Brocq, is preferably carried out with the positive pole 
 and a current of 3 to 10 ma. for one to three minutes; the number 
 of punctures and sessions is increased until a satisfactory result is 
 obtained. [Ultraviolet light with compression often yields good 
 results in the flat varieties.] 
 
 At the present day radiotherapy is furthermore available, but is 
 not always effective when a safe dosage is employed. Radium 
 seems to me to possess a real superiority in this respect, especially 
 in case of tuberous nevi of moderate depth and inconsiderable size ; 
 but care must be taken to guard against radium dermatitis. Flat 
 vascular nevi are advantageously treated with carbonic acid snow, 
 which when skilfully handled leaves only slightly visible cicatrices. 
 Large tuberous angiomas belong to the domain of surgery. 
 
 (c) The progressive multiple angiomas constitute a clinical form 
 not heretofore described; I have observed several instances on the 
 face or on the extremities of young or adolescent individuals. They 
 are represented by at first subcutaneous nodosities, of firm consist- 
 ence, but reducible, which multiply and raise up the skin, giving it 
 a slate-blue hue; later on the skin is invaded and becomes the seat 
 of a purplish depressible growth, which bleeds readily. Ten or 
 fifteen of these tumors, the size of buckshot to that of a large hazel- 
 nut, may be seen strung out on the sole of the foot and on the leg, 
 or scattered over the face. The course lasts from six months to two 
 or three years; ultimately, some of these angiomata spread over 
 very extensive surfaces, with diffuse borders, while others remain 
 stationary or undergo spontaneous retrogression. The differential 
 diagnosis may prove difficult from the pigmentary sarcomatosis of 
 Kaposi, from telangiectatic sarcoma, or from nevo-careinoma, but 
 is established on biopsy, which shows simple cavernous angioma. 
 It is of great importance to treat these angiomata while they are 
 still small with electrolytic punctures, which promptly cure them. 
 
VASCULAR and connective-tissue tumors 
 
 695 
 
 (d) Stellate angioma is a very common nevus, which often appears 
 late, about the time of puberty or still later. It consists of a red 
 and prominent central point, from which radiate telangiectatic 
 arborizations resembling spiders' feet (Fig. 198). It is easily con- 
 trolled by the galvano-cautery heated to a dull red, or better by an 
 electrolytic puncture. 
 
 
 Fig. 198. — Stellate angioma or vascular nevus araneus. 
 
 (e) Senile angiomas [in French "pointes rubis," ruby spots] are 
 punctiform or at most lenticular, slightly prominent angiomas 
 which develop with great frequency and in large numbers on the 
 trunk and the limbs of individuals past forty years of age. They 
 have been credited with the property of indicating a visceral cancer, 
 but this has been shown to be erroneous. They may be considered 
 as delayed vascular nevi. 
 
 (/) The angiokeratoma of Mibelli is observed on the extremities 
 of young individuals with acro-asphyxia, suffering from frost-bite, 
 glandular tuberculosis, etc.; so that Leredde classifies it with the 
 tuberculides. The lesions present the appearance of small spots 
 of a bright red color, grouped or agminated, situated especially on 
 the dorsal aspect of the hands and fingers, rarely elsewhere; their 
 surface generally becomes hyperkeratotic and verrucous. After a 
 few months these angiokeratomas may disappear spontaneously. 
 They may be treated like the senile angiomas with the galvano- 
 cautery. 
 
 In addition to the Mibelli type, hyperkeratoses have been de- 
 scribed as occurring on vascular angiomas and telangiectases of all 
 kinds, notably on the scrotum where they are not very uncommon; 
 I have observed several cases even upon the tongue. 
 
 Lymphangioma.— These very rare tumors occur as the result of 
 a newformation of lymph vessels with dilatation. They are referable 
 to a primary malformation and must be considered as lymphatic 
 
G9G TUMORS OF THE SKIN 
 
 vascular nevi. A confusion with lymphatic varicosities has caused 
 much trouble and, as a matter of fact, the distinction between the 
 two groups is not always easy. In my opinion, these differences 
 may be explained as follows: 
 
 Lymphatic varicosities, or lymphangiectases, are acquired dilata- 
 tions of the lymph channels of the skin and mucous membranes. 
 They are generally a complication of, or substitute for, elephantiasis 
 (Chapter XVIII) and seem to be caused by an obstruction in a 
 lymph vessel or gland as the result of tuberculosis, syphilis, filariasis 
 and especially of recurrent erysipelas. 
 
 Lymphatic varicosities are observed in the mouth, on the mucosa 
 of the lower lip, the cheeks and the tongue, in the form of clear, 
 translucid, beaded or acuminate pseudo-vesicles, of variable number 
 and size; they sometimes become white and opaque; or sometimes 
 red or black through penetration of blood into their cavity. They 
 slightly resemble herpetic vesicles, but are reducible on pressure; 
 moreover, when pricked with a pipette, they furnish an almost 
 unlimited quantity of a clear fluid which is lymph. The subjacent 
 tissues are in a state of chronic edema. Lymphangiectases are 
 frequently associated with elephantiasis of a limb. 
 
 Accordingly, lymphatic varicosities may present themselves 
 without tumors, as acquired lesions secondary to a process causing 
 lymph stasis. On the other hand, they will be shown to form also 
 an integral part of the lymphangiomas. 
 
 Circumscribed lymphangiomas are congenital tumors or they 
 may appear in early childhood. They consist of rose-colored 
 elevations, more or less firm to the touch, conglomerated in patches 
 and covered with lymphatic varicosities. The latter are very com- 
 monly associated with dilated bloodvessels, namely, with heman- 
 gioma, and this combination has been interpreted in a variety of 
 ways [and gives to the patches a mottled polychromatic appearance]. 
 
 Lymphangiomas are preferably situated on the neck and at the 
 root of the limbs; I have observed them also on the flank, in the 
 parotid region, on the knee, etc. They are progressive, but slow and 
 painless, so that the patients put off seeking advice. As a result of 
 interstitial growth, they may give rise to monstrous deformities. 
 The presence of lymphatic varicosities at given points of their surface 
 constitutes their essential distinctive feature. 
 
 Lymphangioma may be treated by extirpation, which is rarely 
 followed by recurrence when complete, or with the galvano-cautery, 
 or by electrolysis; the latter is also suitable for the treatment of 
 simple lymphangiectases. Radiotherapy results in a well-marked 
 but transitory improvement. 
 
 Primary diffuse lymphangioma is identical with congenital ele- 
 phantiasis (Chapter XVIII). 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 697 
 
 Xanthoma. —Under the name of Xanthoma (W. P. Smith) is 
 designated the disease corresponding to Rayer's yellow patches of 
 the eyelids; the vitiligoi'dea of Addison and Gull; the xanthelasma 
 of E. Wilson, etc. 
 
 Until the last few years, the nature of this disease appeared to be 
 very mysterious; as it could not be considered as neoplastic, it was 
 for a short time believed to be of infectious origin. Its affinities had 
 been recognized on the one hand with diabetes or glycosuria, on the 
 other with chronic icterus and diseases of the liver in general. The 
 yellow cast of the skin and mucous membranes as a whole, which 
 is noted in many cases of xanthoma, not necessarily accompanied 
 by choluria, was distinguished from icterus and described as xantho- 
 chromia; it has theoretically been referred to xanthomatous lesions 
 of the biliary passages, which, however, have never been demon- 
 strated. Cases of family or congenital xanthoma were known to 
 occur. 
 
 Recent contributions, for which we are indebted to Pinkus and 
 Pick, but especially to Professor A. Chauffard with Grigaut and Guy 
 Laroche, have shown xanthoma to be related to cholesterinemia. 
 The fatty substance which is abundantly present in the lesions 
 and characterizes them, is not an ordinary fat, that is, a fatty acid 
 glycerine ether, but is a lipoid, a fatty acid cholesterin ester. The 
 new teachings are accordingly as follows: 
 
 Cholesterin, an integral constituent of all body tissues, exists 
 normally in the blood serum in a ratio which, according to Grigaut, 
 oscillates between 1.20 and 1.80 per thousand; it is derived to a 
 small extent from the food but mainly from an internal secretion 
 of various tissues and organs, among which the suprarenal capsules 
 figure predominantly and secondarily the corpora lutea of the ovaries. 
 It is eliminated through the bile, either in its natural state or per- 
 haps in the form of cholalic acid. Its antihemolytic and antitoxic 
 action has been definitely established. Cholesterinemia is increased 
 during pregnancy and in the puerperal state as well as during men- 
 struation; while lowered as a rule at the onset of infections, it is 
 raised in convalescence. Its highest ratio is reached in the course 
 of Bright's disease and especially in icteric conditions due to reten- 
 tion; its relations with diabetes are not constant. 
 
 The conclusion has thus been reached that when the cholesterin 
 is insufficiently eliminated it accumulates in the skin (xanthoma) 
 and in the mucous membranes, likewise in the walls of the arteries 
 (atheroma). Xanthematous deposits have sometimes been found 
 on the endocardium, on the peritoneum and even in ovarian cysts 
 (Malassez and de Sinety). The lesions of xanthoma, being prin- 
 cipally due to this deposit of cholesterin, may be considered up to a 
 certain point as retention-tumors. 
 
69S 
 
 TUMORS OF THE SKIN 
 
 Clinically, xanthoma presents itself under four forms: 
 A. Xanthoma plan nut of the eyelids, which has received the special 
 name of xanthelasma, is the most common. It consists of straw 
 yellow or dusky, distinctly outlined, sometimes slightly prominent 
 spots which are located more or less symmetrically on the most 
 internal portion of the eyelids (Fig. L99). Their seat, their extent 
 and their color serve to distinguish them from the hidradenomas 
 and the sebaceous adenomas of this region. Xanthelasma usually 
 develops insidiously in adults and aged individuals, somewhat 
 more frequently in women, as a solitary manifestation of xanthoma, 
 often without apparent disturbance of the general health. But I 
 
 199.— Xanthelasma of the eyelids 
 
 have noted its rather abrupt onset in the course of hypertrophic 
 cirrhosis with icterus. It sometimes becomes associated with one 
 of the following forms: 
 
 B. Eruptive xanthoma xanthoma tuberosum multiplex — is more 
 uncommon; it may he met with at any age, even in young children 
 (Plate IV). It consists of papular or tuberous elevations, having 
 the dimensions of a pin-head to those of a large bean, of a golden 
 yellow color with a pinkish areola, or it may be of a dark more or 
 less purplish red; in the latter case, the yellow hue of the lesions 
 can be demonstrated by means of vitropressure. Their consistence is 
 sometimes soft, in other cases solid or even keloidal. The eruption 
 
PLATE IV 
 
 m 
 
 
 j 
 
 ./ # 
 
 
 j 
 
 i 
 
 Eruptive Xanthoma, in a Child of Four Years. 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 699' 
 
 may be slow, progressive, appearing in successive crops; or it may 
 be sudden, becoming established in less than a month ; occasionally, 
 the yellow papules make their appearance upon persistent erythe- 
 mato-urticarial spots. 
 
 The lesions vary greatly in numbers in different cases and are 
 sometimes pruritic or painful. They are somewhat symmetrically 
 arranged, especially on the elbows, the knees, the shoulders, the 
 buttocks, the finger-joints and the scalp. Xanthoma may be said 
 to favor high places. This localization is perhaps referable to the 
 fact that these regions are more exposed to blows and to friction, 
 for yellow linear streaks are not infrequently observed at the same 
 time on the flexion-folds of the palmar and plantar regions and the 
 fingers, as well as xanthelasma of the eyelids; in other words, the 
 xanthomatous infiltration preferably takes place at points where 
 the skin is often folded or bruised; Chauffard observed a patient in 
 whom every puncture for arsenic-injection became the center of a 
 xanthomatous nodule. 
 
 The lesions persist indefinitely, or they may become absorbed and 
 disappear. There is no reason, however, to distinguish with [M. 
 Morris] Robinson and Torok an acute, temporary or intermittent 
 form, constituting diabetic or glycosuria xanthoma. [The glycosuric 
 form is however clinically distinguished by the presence of a vivid 
 red zone on the sides and surrounding the base of each nodule, an 
 appearance extremely rare in the non-glycosuric form.] 
 
 C. Congenital xanthoma, in tumors, manifests itself in the form 
 of prominent, globular or conglomerated, sessile or pedunculated 
 newformations of a yellow, dusky or purplish color, soft or fibrous 
 and hard, which may attain the size of a mandarin orange or larger. 
 They occupy the crest of the elbows (Fig. 200), the knees, the 
 shoulders, sometimes still other regions. These tumors are present 
 at the time of birth, or make their appearance in the course of the 
 first months of life. 
 
 D. Secondary xanthomatization has been seen in various tumors, 
 notably in nevi. I was enabled to study a cutaneous fibroma which 
 was histologically xanthomatous, as well as a xanthomatous rhab- 
 domyoma of the tongue; Pollitzer observed one on the eyelids. 
 This cholesterin infiltration of all kinds of neoplasms is very readily 
 accounted for at present. 
 
 It seems advisable in this connection to point out that pseudo- 
 xanthoma elasticum (p. 358), the first reported cases of which were 
 confused with xanthoma, is a cutaneous dystrophy of altogether 
 different character. 
 
 Pathological Anatomy. — The blood of xanthomatous patients is 
 far from always being distinctly lipemic, with milky serum. The 
 highest ratio of cholesterinemia noted by Chauffard (1910) in 
 patients having xanthelasma is 1.90 per thousand; in multiple 
 
700 
 
 TUMORS OP THE SKIN 
 
 xanthoma the blood has been found to contain 6.0 or more of 
 cholesterin per thousand. 
 
 The histology of xanthoma shows that the lesions are made up by 
 collections in the cutis of large connective-tissue cells of very special 
 appearance, polyhedric or spindle-shaped, often arranged concen- 
 trically around the vessels, frequently with a compressed central 
 nucleus and a vacuolated foamy protoplasm; their vacuoles enclose 
 fatty granules which will be discussed presently; these are the 
 xanthelasmic cells of Chambard, now known as xanthomatous cells; 
 in certain cases a considerable number of these are polynuclear and 
 giant cells. The xanthomatous cells are arranged in nodules or in 
 strands separated by bands of connective and elastic tissue. There 
 
 Fig. 200. — Xanthoma in tumors, in a girl, aged nineteen years. Similar tumors 
 existed on the other elbow and on both knees, with xanthelasma of the eyelids. 
 
 sometimes seems to be a fibrous reaction which encloses the special 
 constituents and gives to the whole a fibromatous consistence. The 
 epidermis is normal or loaded with pigment. The fatty substance 
 peculiar to xanthoma generally assumes the form of fine granules or 
 round droplets, but sometimes also that of crystals in small rods or 
 in hue needles united in clusters. It is for the most part contained 
 in the xanthomatous cells, although some of it is also almost invari- 
 ably found in the intercellular spaces. It is soluble in strong 
 alcohol, in ether and essential oils; heat melts it, so that in order to 
 see it, the fresh specimen must be fixed with chromates or better 
 with osmic acid or Flemming's fluid, or with formol; or cut as 
 fro/en sections and mounted in glycerine. It will be found that a 
 considerable part of these granules stain poorly with osmic acid, 
 take an orange red stain with Soudan III and, as was first observed 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 701 
 
 by Stoerk, present the phenomenon of double refraction with 
 polarized light; this is therefore not ordinary glycerine-fat, but 
 rather a cholesterine ether. Other granules are stained a deep black 
 with osmic acid, are turned red by the Soudan reagent and remain 
 dark when the prisms of the polariscope are crossed; these are 
 ordinary fats. The two kinds of granules, which with Policard and 
 Mangini I have usually found to exist together in xanthomas, are 
 variably distributed in the lesions. Histologically the difference 
 between a simple deposit or an active absorption of these substances 
 by the perivascular connective-tissue cells cannot be determined. 
 
 [In my opinion, xanthoma tuberosum multiplex, the eruptive disseminated 
 form, and xanthoma planum or xanthelasma, the form that occurs on the 
 eyelids, are two distinct diseases. My studies on this subject have been 
 published in the New York Med. Jour., 1898, Jour. Cutan. Dis., 1910, xxviii, 
 633, and, in collaboration with U. J. Wile, ibidem, 1912, xxx, 235. I present 
 here the principal points of difference between the two diseases: 
 
 
 1. Prominent, hard, round or lobulated 
 tumors. 
 
 2. Occurs at any period of life but pref- 
 erably in early adult life and childhood. 
 
 3. Development rapid, in a few weeks 
 or months. 
 
 4. Disappears after months or years, 
 or undergoes fibrous changes and persists 
 indefinitely. 
 
 5. Extremely rare. 
 
 6. Distribution general with the neigh- 
 borhood of the large articulations as seat 
 of predilection. (Under the tense epi- 
 thelium of the palms the tumors may be 
 spread out in stria? along the normal folds.) 
 
 7. Histologically, xanthoma is an irrita- 
 tive connective-tissue-cell hyperplasia, 
 due to the presence of cholesterol fatty- 
 acid esters derived from the blood. The 
 process begins in the cells of the vascular 
 adventitia, which take up the extruded 
 fatty particles, increase in size and pro- 
 liferate, sometimes becoming multinu- 
 cleated. These cell masses in turn 
 commonly act as stimulants to the pro- 
 duction of fibroblasts, resulting, in old 
 xanthomas, in the development of fibro- 
 mas which have erroneously been inter- 
 preted as the primary tumor, "xantho- 
 fibroma." Xanthoma connotes a systemic 
 disease, a disturbance of metabolism.] 
 
 Xanthelasma. 
 
 1. Flat, soft, indistinguishable on pal- 
 pation, or if at all prominent, feels like a 
 bag of fat. 
 
 2. Practically unknown before middle 
 age. 
 
 3. Development slow, extending over 
 years. 
 
 4. Persists unchanged through life; 
 never undergoes fibrosis. 
 
 5. Quite common. 
 
 6. Limited to face and neck, the region 
 of voluntary cutaneous muscles. 
 
 7. No signs of connective tissue or other 
 inflammatory changes. It occurs only 
 when there are striated muscle fibers in 
 the skin, that is, the face and neck 
 (platysma), but similar degenerations 
 have been observed in the tongue, the 
 uvula and in congenital myomata and are 
 reproduced to some extent in the waxy 
 degeneration of muscles after typhoid, 
 etc. The so-called xanthoma cells of 
 xanthelasma are cross-sections or frag- 
 ments of muscle fibers of the orbicularis 
 palpebrarum which have undergone a 
 peculiar cholesterol fatty degeneration 
 with proliferation of sarcolemma nuclei. 
 Xantho-myoma does not occur ; so far from 
 a tumor or increase of the muscle tissue 
 there is, on the contrary, a disappearance 
 of muscle fibers. In long-standing xanthe- 
 lasma there is scarcely anything left of 
 the original muscle in the areas affected. 
 Xanthelasma is independent of any 
 known general disorder. It belongs with 
 the cutaneous degenerations.] 
 
702 TUMORS OF THE SKIN 
 
 Treatment. — As a rule, xanthoma shows a tendency to persist 
 and increase. The undesirable spots of xanthelasma and even the 
 xanthomatous papules can be made to disappear, however, almost 
 without cicatrices, by very careful cauterization with the galvano- 
 cautery, heated to a dull red. The classical medication with tur- 
 pentine in capsules, which has long been followed, seems advantage- 
 ous. At the present day, however, the treatment must obviously 
 be based upon the hypocholesterin diet, recommended by Chauft'ard, 
 consisting of roasted and broiled meats, green vegetables, skimmed 
 milk, fruits and sugar. 
 
 Tophi of Gout. — If the modern interpretation of xanthoma is 
 correct, this disease presents great analogies with gout. The uric 
 acid which circulates in excess in the blood in the last-named 
 dyscrasia, is deposited not only in the joints and the peri-articular 
 tissues and sometimes in the viscera, but frequently also in the skin. 
 The urates deposited in the cutis and the cellular tissue are known 
 as tophi. According to Garrod and Charcot, who made a special 
 study of the subject, tophi are found in nearly one-half of all gouty 
 patients (lb times in 37 cases). 
 
 Their seat of election is on the external ears, in the groove or on 
 the sharp border of the helix, where these concretions, from one or 
 two to about ten in number, constitute small tumors the size of a 
 millet-seed to a pea. Their color is normal or purplish, with an 
 opaque white hue shining through it. Tophi have occasionally 
 been observed in various other regions; on the ala? or on the bridge 
 of the nose, on the scalp, on the eyelids, etc. 
 
 Their other common seat is in the vicinity of gouty joints, over 
 the olecranon or the prepatellar bursa for example, or around the 
 joints of the fingers and toes. These tophic concretions are sub- 
 cutaneous or intradermic; at first small and multiple, they tend to 
 become agglomerated and spread out. Soft at first, they subse- 
 quently become extremely hard. 
 
 Tophi make their appearance as a rule after attacks of gout, 
 causing slight inconvenience and sometimes disappearing spon- 
 taneously ; in other cases, abscesses develop, or still more frequently 
 the skin becomes stretched, opens without suppuration and permits 
 the escape of a chalky substance chiefly composed of sodium urate. 
 Under the microscope it appears as circular crystals, soluble in hot 
 water, which on treatment with acetic acid yield uric acid crystals; 
 with nitric acid and ammonia, the murexide reaction is obtained. 
 
 In contradistinction to lime concretions, urate concrements are 
 transparent to the .r-rays. It has been suggested to treat them by 
 means of lithium ionization. The simplest way to get rid of tophi 
 on the ears is extirpation with the curette, under local anesthesia. 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 
 
 703 
 
 Urticaria Pigmentosa.— The name given to this affection by 
 Nettleship is not a good one, in so far as it leads to confusion with 
 pigmented urticaria (Chapter II). 
 
 Urticaria pigmentosa (xanthelasmoidea of T. C. Fox) is not a 
 variety of urticaria, but a chronic skin disease which histologically 
 is ranged with the retention tumors. 
 
 -Urticaria pigmentosa in the 
 resting state. 
 
 Fig. 202. — The same urticaria pigmen- 
 tosa in the urticarial state, after irrita- 
 tion by energetic rubbing. 
 
 It is characterized by spots or not very prominent elevations, from 
 a pin-head to a fingernail in size, of a dusky or tawny color; these are 
 distributed over the integument in variable number, from a dozen 
 or so to several hundreds, situated especially on the trunk and on the 
 limbs, but sometimes also on the head and the extremities. 
 
 The pathognomonic sign of urticaria pigmentosa consists in the 
 inherent property of these spots or elevations to become congested, 
 swollen, firm and distinctly urticarial under the influence of active 
 scratching or pressure with a blunt instrument (Figs. 201 and 202). 
 
 This sign by itself alone would suffice to differentiate these lesions 
 from those of lichen planus, psoriasis, syphilides or tuberculides,, or 
 from simple macules which they sometimes closely resemble * 
 
70-4 TUMORS OF THE SKIN 
 
 The usual teaching is to the effect that urticaria pigmentosa begins 
 a short time after birth, rarely after the first year; that it disappears 
 at the end of eight or ten years through progressive obliteration and 
 would accordingly be very rare in adults. This is often correct. I 
 have shown, however, before the French Dermatological Society 
 in 1905, that this affection may last indefinitely; that its appear- 
 ance may be noted at puberty or even at a mature age; that it is 
 sometimes familial. The eruption in some cases is subject to con- 
 gestive attacks with pruritus, spontaneous or in connection with 
 sweating; in other cases, it remains sluggish and latent, so that its 
 existence may be overlooked on superficial examination. The exist- 
 ence of dermographism has been reported in these patients; this may 
 be a mere coincidence and at all events is not common. 
 
 The histology of the lesions shows in the cutis an abundant 
 infiltration of mast-cells, staining a purplish red with polychrome 
 blue; these cells are spindle-shaped, oval or polygonal when ac- 
 cumulated in masses. Pigment is found in the basal layer of the 
 epidermis and in the papillary body. 
 
 The etiology is unknown. Cutaneous irritation, nervousness and 
 emotional disturbances have been held responsible. It seems to 
 me that auto-intoxications of digestive origin or certain disturb- 
 ances of the hepatic function may play a role. Investigations 
 aiming at the separation of the complex of hepatic insufficiency and 
 biliary retention may help to elucidate this problem, as in the case 
 of xanthoma. If I am mistaken in this hypothesis, urticaria pig- 
 mentosa will have to be considered as related to the nevi. 
 • All treatment hitherto attempted, including hot and cold hydro- 
 therapy, radiotherapy, phototherapy, electrolysis, etc., has on the 
 whole proved useless. All that can be done is to prescribe a correct 
 hygiene. 
 
 Botryomycoma [Granuloma pyogenicum]. — This designation is 
 applied to certain benign tumors, or rather persistent inflam- 
 matory products which assume the behavior of tumors, possessing 
 very peculiar morphological and histological features. 
 
 There is sometimes seen on the hands or on the fingers, or on the 
 sole of the feet, a small soft prominent elevation, bright red in color, 
 smooth or resembling a raspberry, the size of a pea to that of a 
 large hazel-nut; its essential feature consists in its being strangulated 
 at the base, or even plainly pedunculated, as may be verified in 
 doubtful cases with the help of a stylet or a hook. Less commonly, 
 similar growths have been observed on the leg, the forehead, the 
 lips and elsewhere. As a rule the patient will remember some 
 puncture or wound which he has sustained at this point and which 
 has been suppurating for a few weeks or months previously. He will 
 
VASCULAR AND CONNECTIVE-TISSUE TUMORS 
 
 705 
 
 generally admit having repeatedly cauterized or irritated it in various 
 ways. These tumors may persist for years (Fig. 203). 
 
 On histological examination they are found to consist of inflam- 
 matory or embryonic connective tissue with large and abundant 
 newly formed capillaries; briefly, showing the structure of chronic 
 "proud flesh" [granulation tissue]. The epidermis is missing on 
 their surface and usually stops at the level of the pedicle or slightly 
 above it. 
 
 Fig. 203. — Botryomycoma of seven months' standing irritated by traumatism and 
 applications of nitric acid. 
 
 The interest aroused by these peculiar small products and the 
 inappropriate name they bear are due to the statement of Poncet 
 and Dor, in 1897, to the effect that these inflammatory growths 
 contained mulberry-shaped hyaline globules, sometimes visible to 
 the naked eye, similar to those which had been described by Bol- 
 linger under the name of botryomyces in the fungoid growths follow- 
 ing castration in horses; it is now known that this appearance is 
 not due to a parasite, but to cellular dege nerations of pycnotic type. 
 
 Moreover, the coccus growing in yellow cultures which can be 
 isolated from human as well as animal botryomycoses possesses no 
 special features and is not entitled to the name of botryococcus 
 ascoformans, applied to it by Kitt; it is nothing more nor less than 
 the Staphylococcus aureus. It would therefore be justifiable to 
 group the tumors caused by it under the heading of pyococcal 
 dermatoses. 
 
 [The name Botryomycoma, based on an erroneous pathogenesis, 
 is obviously objectionable. The term granuloma pyogenicum , pro- 
 posed by Hartzell, is to be preferred.] 
 45 
 
706 TV MORS OF THE SKIN 
 
 The treatment of these newformations consists in their complete 
 ablation [followed by cauterization]; there is no danger of recurrence. 
 [Nevertheless, unless they are thoroughly cauterized they often 
 recur.] 
 
 SARCOMA. 
 
 Sarcomas are connective-tissue tumors of embryonic structure, 
 usually possessing great malignancy. 
 
 On the skin are observed: primary idiopathic .sarcoma, which 
 alone will be considered here; and secondary metastatic sarcoma, 
 derived from the generalization of sarcomatous tumors of the viscera, 
 the glands or the bones. 
 
 The primary cutaneous sarcomata belong to different varieties. 
 From the histological point of view, a distinction can be made 
 between the following: 
 
 1. Round-cell .sarcoma, which consists either of small round cells 
 or of large round cells. 
 
 2. Spindle-cell sarcoma, with spindle-shaped or fasciculated cells. 
 
 3. Atypical sarcoma with polymorphous cells which were errone- 
 ously described by me in former publications and in the first 
 edition of this book, under the name of lymphosarcoma. 
 
 The so-called pigmented sarcoma is a nevocarcinoma (p. 682) 
 which surgeons persist in calling melanotic .sarcoma. The multiple 
 idiopathic pigmented sarcoma of Kaposi (1872) is a separate affec- 
 tion, probably of infectious origin. 
 
 A. Typical Sarcoma. — These tumors are characterized by their 
 being composed almost exclusively of embryonic connective-tissue 
 cells, all of the same type, round or spindle-shaped in different cases, 
 not contained in an adenoid network and whose bloodvessels are 
 lacunar, in the sense that their walls are formed by the tumor 
 constituents themselves. 
 
 This neoplasm of relatively homogeneous structure invades the 
 neighboring tissues by substitution, not by interstitial infiltration; 
 metastases occur by way of the bloodvessels rather than by the 
 lymphatic route. These features are not invariable, however, for 
 any sarcoma may present some rare dissimilar constituents, chorio- 
 plaxes, giant cells, etc., as well as points of interstitial infiltration 
 on sonic of its borders. 
 
 Spindle-cell or fascicular .sarcoma, with large or small fusiform 
 cells arranged in interlacing bundles, presents itself clinically under 
 the aspect of a hard, indistinctly outlined dermo-hypodermic tumor, 
 of a dark red or purplish color, interspersed with telangiectases; 
 it grows slowly and finally becomes superficially ulcerated; it has 
 only a slight tendency toward glandular or visceral metastases, but 
 usually recurs promptly after surgical removal, 
 
SARCOMA 
 
 707 
 
 Round-cell sarcoma, with small or large round cells, develops 
 more rapidly and usually becomes generalized. The initial tumor 
 may be situated at any point of the body, except on the extremities ; 
 whether operated upon or not, it becomes associated after a few 
 months with secondary tumors in progressive number, from about 
 twenty to several hundreds, first in the same region, then scattered 
 on the trunk, the root of the limbs and the head with relative 
 freedom of the hands and feet. Some of the tumors are at first 
 hypodermic and movable under the skin, which presents a lavender 
 hue and an orange-peel appearance, before it becomes invaded. 
 Other tumors are dermic, pink, dark red, then purplish, the size of 
 a pea or a hazel-nut to that of a mandarin orange, of hard or soft 
 
 Fig. 204. — Generalized sarcomatosis. Woman, aged fifty-two years; onset in the 
 pectoral region three years before; death in the course of the fourth year. 
 
 consistence; after a certain time, they undergo ulceration through 
 necrosis; followed by fever, diarrhea, hemorrhages, finally death 
 due to cachexia, after a total duration of one to four years. The 
 glands are found to be intact, but metastases are sometimes found 
 in the lungs, liver and spleen. The blood at the period of the ulcer- 
 ations presents a leukocytosis of 20,000 to 40,000, with predominance 
 of the polynuclears. This pathological type, known as generalized 
 sarcomatosis (Fig. 204) is observed especially in patients between 
 forty-five and sixty years of age. 
 
 Angiosarcoma is a malignant tumor, frequently multiple, de- 
 veloping slowly in adults, more rapidly in children, consisting of 
 fascicular sarcomatous tissue with telangiectases; opinions differ 
 
708 TUMORS OF THE SKIN 
 
 as to its being an angioplastic sarcoma or an angioma which has 
 become sarcomatous. These tumors have been observed especially 
 on the scalp, in the upper part of the face and on the upper part of 
 the trunk. 
 
 Sarcomas with myeloplaxes are extremely rare and seem to be 
 secondary to tumors of the bones. 
 
 Parini is said To have observed a case primary in the skin. 
 
 B. Atypical Sarcoma with Polymorphous Cells. — I have repeatedly 
 drawn attention to this form of sarcoma, under the name of "lympho- 
 sarcoma:" this denomination has the disadvantage of creating con- 
 fusion by suggesting the identity of this form with the glandular 
 lymphosarcoma of Kundrat-Paltauf (p. 653); since this identity 
 seems to me in no way established, nor even probable, I have adopted 
 the denomination given above, in my report of an illustrative case 
 (Annates de Dermatologie, April, 1911, p. 220). 
 
 This form of sarcoma is characterized histologically by a very 
 special, alveolar or areolar structure on account of which it has 
 received from the old anatomo-pathologists the names of alveolar 
 sarcoma (Billroth) and reticular carcinoma (Cornil and Ranvier). 
 The more or less dense network is sometimes adenoid, composed of 
 fine fibrils, while in other cases it consists of larger fibrous strands, 
 provided with connective-tissue cells ; or again it may be embryonic 
 and myxomatous; or it may vary in appearance at different points 
 of the same tumor. The constituents enclosed in its meshes are con- 
 nective-tissue cells of embryonic or fetal type and very polymor- 
 phous, being small and round, or rather large and round, or fusiform 
 and stellate, sometimes multinuclear; among them plasmocytes are 
 sometimes met with, but very few or no lymphoid or myeloid con- 
 stituents; the polynuclears are numerous in ulcerated tumors. 
 The bloodvessels, instead of being purely lacunar as in the other 
 sarcomata, have distinct walls, but without elastic fibers. The 
 boundaries of the tumor are less distinctly outlined than those of the 
 other sarcomas. 
 
 Clinically, these polymorphous alveolar sarcomas are, after the 
 epitheliomas, the most common primary malignant tumors of the 
 skin. They are observed in both sexes, in adolescence or adult life, 
 preferably in the vicinity of the natural orifices. 
 
 The process begins as a small pink intradermic nodule, of firm 
 consistence; this develops in breadth rather than in thickness, 
 finally giving rise to a large, hard, globular or spreading tumor, 
 which for a long time remains solitary, more or lesss rapidly under- 
 going erosion or ulceration. A large and hard, sometimes also 
 ulcerated glandular enlargement is noted at an early stage, which 
 does not occur in any other form of sarcoma. Secondary nodules 
 finally develop in the vicinity; generalization takes place by the 
 lymphatic route, as in the case of the epitheliomas. 
 

 
 SARCOMA 709 
 
 This variety is thus seen to differ in many respects from the so- 
 called typical sarcomas. 
 
 C. Multiple Hemorrhagic Sarcomatosis. — This designation is 
 applied to a disease which is clearly differentiated by its clinical 
 behavior and by the structure of its lesions; their character, how- 
 ever, is probably very different from that of the sarcomas. It is 
 the idiopathic pigmented sarcoma of Kaposi. 
 
 It begins at the extremities, or as a solitary tumor at any point, 
 sometimes as the sequel of a local traumatism; lesions promptly 
 develop on the feet and hands, nearly always symmetrically. 
 
 There are either very hard edematous swellings, livid or slate- 
 colored, in spots or in patches, often imperfectly outlined; or 
 small tumors, miliary or pea-sized, at first intradermic, then pro- 
 tuberant or even pedunculated, often agminated. These tumors, in 
 very variable number, appear on the infiltrated surfaces as well as 
 on the healthy skin; they vary in hue from a dark rose color to 
 purplish and black; hemorrhagic spots are likewise noted. The 
 lesions progress from the periphery to the center; after the legs and 
 the forearms, the thighs, the genital organs, the mouth, the back and 
 finally the internal organs are invaded. Movements are consider- 
 ably impaired, but the pain is moderate; the tumors and infiltra- 
 tions never assume a marked development, they have only a slight 
 tendency to ulcerate and are even capable of undergoing sponta- 
 neous absorption. The glands usually remain free. The general 
 health may be good until the terminal stage is reached. 
 
 Kaposi's sarcomatosis attacks especially men from forty to sixty 
 years, particularly laborers, but sometimes children. It lasts from 
 two to ten years and leads to death through generalization, with 
 fever, cachexia, hemorrhages, etc. It is not rare in Poland, Russia, 
 Austria and Italy, but altogether exceptional in France. [In 
 America it occurs almost exclusively among Jews, possibly because 
 the great majority of our Russian, Austrian and Polish immigrants 
 belong to this race.] 
 
 Histologically, the lesions consist of a newformation of dilated 
 capillary bloodvessels, with lymphatic dilatations and collections of 
 round and fusiform cells arranged parallel with the vessels in vari- 
 able proportions. The pigment is hemosiderin, of hemorrhagic 
 origin. 
 
 There is a tendency to question the neoplastic character of this 
 disease and to consider it as infectious; its pathogenic agent is 
 unknown; it is not auto-inoculable and does not seem to be con- 
 tagious. 
 
 Diagnosis of the Sarcomas. — As many sarcomas are hypodermic 
 at the onset, their differential diagnosis must be made from all the 
 nodosities (Chapter XIV), the gummas and especially the sarcoids, 
 
710 TUMORS OF THE SKIN 
 
 and furthermore from the benign subcutaneous or cutaneous tumors, 
 and from adenitis or certain subacute or chronic phlegmons. 
 
 Secondary carcinoma of the skin, nevo-carcinoma, cylindroma, 
 mycosis fungoides, the leukemic tumors can sometimes be differ- 
 entiated only with considerable difficulty. 
 
 The polymorpho-cellular sarcoma may closely resemble epithe- 
 lioma, certain forms of cutaneous tuberculosis and even syphilitic 
 chancre. 
 
 The hemorrhagic sarcoma of Kaposi must be distinguished at the 
 onset from nevo-carcinoma, from botryomycoma, from scleroderma; 
 and in the course of its development, from the tertiary syphilides, 
 from lupus and more particularly from leprosy, certain cases of 
 which have very closely simulated it in my experience. 
 
 In all doubtful cases, biopsy and histological examination as well 
 as cytological analysis of the blood will be required for the confirma- 
 tion of the diagnosis; it is advisable to resort to these procedures 
 even when the clinical features and the course seem more or less 
 convincing by themselves. 
 
 Treatment. — Surgical removal is to be recommended only at the 
 very beginning, before generalization has had time to occur and must 
 be as early and extensive as possible. In its absence, or directly 
 afterward and as complementary measures, the following treatment 
 should be employed: 
 
 Arsenic has at all times been universally advocated against every 
 form of sarcoma; it is given in large doses and particularly in hypo- 
 dermic injections of potassium or sodium arsenite. At the present 
 day, intravenous injections of arsenobenzols are of course entitled 
 to a preference. It has seemed to me as to many others, that the 
 progress of sarcoma is delayed for some time under the influence of 
 arsenic. [On the use of arsenic in chronic diseases see my note p. 661 .] 
 
 The other treatment which has been found of value, at least in a 
 certain number of cases, is radiotherapy; it has not been demon- 
 strated that radium is more efficient, except in certain regions not 
 readily accessible to the .r-ray tube. The .r-rays are certainly 
 capable of diminishing the size and even of causing the absorption 
 of sarcomas, but this is far from saying that they can effect a com- 
 plete cure. Of course, large doses are administered in such cases; 
 opinions differ concerning the necessary degree of filtration and the 
 general plan of the treatment which notwithstanding the gravity 
 of the condition must nevertheless be cautiously conducted. It 
 goes without saying that these two therapeutic procedures may and 
 should be employed concurrently. 
 
 Unfortunately, the physician is often consulted too late, when 
 generalization is under way and all treatment has become powerless; 
 so that sarcoma still has an extremely serious prognosis. 
 
APPENDIX. 
 
 THERAPEUTIC NOTES. 
 
 On undertaking the treatment of a dermatosis, as with any other 
 pathological condition, it is necessary to look into the therapeutic 
 indications to begin with, as soon as a positive diagnosis has been 
 made. What is to be done? What kind of medication may prove 
 beneficial? By what kind of intervention may one hope to cure, 
 that is, to restore the organism, as far as possible, to a normal 
 condition? 
 
 The choice of the method must therefore necessarily precede the 
 choice of the remedy. Nothing could be more unreasonable than 
 to take up a formulary and blindly order some medicinal compound, 
 without knowing the mechanism of its action and consequently the 
 effects which it may produce. 
 
 The reason for the selection of a given remedy is sometimes 
 supplied by the cause of the disease, when this is known and can be 
 so acted upon as to remove it (examples : scabies, syphilis) ; in other 
 cases it is the pathogenic mechanism which can be influenced; but 
 more frequently, at least in dermatological practice, the lesions 
 themselves dictate the mode of intervention, according to their 
 nature, morphology and degree. It is really of minor importance 
 from the therapeutic point of view, if an acute eczematiform derma- 
 titis, for instance, be due to a physical or mechanical agent, or to 
 this or that chemical substance; what has to be checked is the 
 inflammation, the oozing, itching, etc.; what has to be foreseen, in 
 order to prevent it, if possible, is the superadded infection; what 
 must be aimed at is not to inhibit but on the contrary to favor 
 cellular regeneration. 
 
 At the end of each section of this book, I have taken pains to 
 indicate briefly the kind of medication adapted to the cutaneous 
 affection or to the disease under consideration. 
 
 Here I propose to enter into greater detail concerning some of the 
 modes of treatment. 
 
 It would be a waste of time, at the present day, to compare the 
 relative value of internal and external treatment in dermatology. 
 Each has its own domain, determined by the cause and nature of the 
 
712 APPENDIX 
 
 pathological process on the one hand and by the general condition of 
 the patient on the other. Xo general remarks of practical value in 
 this connection are possible. 
 
 I shall not dwell upon the different measures which constitute 
 the armamentarium of the general treatment of skin diseases; these 
 belong to the domain of general medicine. It goes without saying 
 that the general hygiene, the cutaneous hygiene, the diet (to which a 
 paragraph will be devoted at the end of this chapter) and even the 
 emotional hygiene — all of which play a part in the etiology of certain 
 cutaneous affections, require great attention and must be corrected 
 in a considerable number of cases. 
 
 In the course of this work, I have repeatedly pointed out the 
 advantages offered by hydrotherapy, climatotherapy, heliotherapy, 
 watering-places, the various groups of sera, by opotherapy, vaccino- 
 therapy, ferments and yeasts, etc. 
 
 In regard to internal pharmaceutic remedies, I have had occasion 
 to supply some information concerning those of capital importance 
 or most frequently employed in dermato-therapy (arsenic, arseno- 
 benzols, mercury, etc.). A lengthy discussion of this subject would 
 take me beyond the limits assigned to this book. I restrict myself 
 to the reminder that the medicinal agents most frequently required 
 include the following: the laxatives, quinine, cod-liver oil, calcium 
 salts, phosphoric acid, phosphates and glycerophosphates, iodides 
 and iodine-tannin preparations, chaulmoogra oil, sulphur and its 
 compounds, iron, valerian, etc. 
 
 The local treatment likewise comprises various procedures or 
 modes of action; their indications have been mentioned, but they 
 cannot here be described in detail. 
 
 They can be classified under four headings, as follows: 
 
 1. Surgical extirpation, applicable especially to a large number of 
 tumors, certain cases of lupus, etc. 
 
 2. Dermatological operations, curettage, scarifications, epilation, 
 and cauterization; this technic and the results which can be obtained 
 are admirably described in the writings of my colleague and friend 
 Dr. Brocq, notably in his Traite de Dermatologie pratique (O. Doin, 
 Paris, 1908, Vol. I), to which the reader is referred. 
 
 3. The different forms of physico-therapy (electrolysis, static 
 electricity, Franklinization, high frequency, radiotherapy with 
 .r-rays, radium and radio-active substances, phototherapy, light- 
 baths, Bier's method, treatment with hot-air or carbonic acid snow, 
 massage, etc.). These methods are described in special text-books 
 and it would be futile to offer a necessarily very incomplete and 
 inadequate summary. 
 
 4. External medicinal treatment. 
 
THERAPEUTIC NOTES 713 
 
 This chapter is devoted almost exclusively to the external medi- 
 cinal treatment. 
 
 No complete dermatological formulary should be looked for, as 
 I have on the contrary endeavored to incorporate in these notes 
 only the customary substances and prescriptions or those with 
 which I am personally acquainted. It has long been may conviction 
 that good dermatologic treatment is practicable with the help of a 
 very limited number of procedures and remedies. Inexperienced 
 practitioners even more than experts in the field should refrain from 
 experimenting with poly-pharmacal medication, but unfortunately 
 the contrary is often the case. 
 
 The order followed in my account is that of the remedies which 
 correspond to the clinical indications. Although it seems to be 
 logical and convenient enough, the fact must not be overlooked 
 that an arrangement on this basis possesses more apparent than 
 real value. 
 
 Many medicinal agents, including some of the most valuable, 
 have an unknown or hypothetical mode of action; furthermore, the 
 same substance may have multiple effects ; moreover, its action may 
 be entirely different, or even opposite, according to the concen- 
 tration in which it is employed, according to the duration of its 
 application and according to its pharmaceutic form or its vehicle. 
 
 The 'pharmaceutic form, or let us say the physical state of an 
 active or inert substance which is utilized as a topical agent, has a 
 marked influence on its effects; this very important fact has been 
 brought out by the contributions of Unna and his school. Some 
 explanation here may not be superfluous. 
 
 The skin under normal conditions is covered with a protective 
 layer, the horny epidermis. 
 
 The latter, composed essentially of keratine and fat, forms on its 
 surface a sort of supple and resistant varnish, practically imper- 
 meable to water and aqueous solutions, but more or less permeable 
 to fatty bodies, volatile substances and gases. 
 
 Perhaps the most important function of the horny layer is to 
 oppose the evaporation of water from the body tissues; without it, 
 an enormous loss of water would take place over a surface as exten- 
 sive as that of the entire integument and at the temperature of the 
 body. However, undoubtedly due to the sweat pores and follicles 
 with which it is riddled, the normal skin is constantly the seat 
 of a fairly considerable watery evaporation known as "insensible 
 perspiration." This contributes powerfully to the regulation of the 
 general temperature of the body and the local temperatures of the 
 various tegumentary regions. 
 
 It is now necessary to keep in mind the modifications which this 
 
714 APPENDIX 
 
 physiological function may undergo through pathological changes 
 of the skin on the one hand and through topical applications on the 
 other. When the skin is congested or inflamed or when its horny 
 covering is absent or defective, the evaporation is considerably 
 increased. Among the topical agents, those which tend to increase 
 evaporation are necessarily cooling and relieve congestion; whereas 
 those which inhibit evaporation will have a heating and congestive 
 effect. 
 
 The mode of action of the customary agents of topical treatment 
 will be briefly examined in the following, in the light of the above 
 data. First, however, it seems advisable to point out a mistake 
 very frequently committed in practice, but which it is important 
 to avoid; it consists in the application of alterative dressings, 
 ointments or medicated plasters over crusts, scales, or hyperkeratotic 
 layers. Even if the topical agent be judiciously selected, it must be 
 remembered that the remedy is separated from the surface on which 
 it is to act by a stratum or layer of dead and isolating substances. 
 Xo one would dream of interposing a sheet of paper or a bit of shirt 
 between an application and the diseased skin! // is therefore always 
 necessary at the start to cleanse, denude or freshen, every tegumentary 
 lesion which it is proposed to treat. 
 
 Water and Watery Solutions. — Baths, douches, sprays, washes and, 
 better still, poultices and moist occlusive dressings whose action is 
 more prolonged, are the most efficient and most commonly utilized 
 cleansing agents; their general effect is moreover to relieve conges- 
 tion. The macerated epidermis becomes more permeable. 
 
 Alcoholic, Ethereal Solutions, etc. — Alcohol, ether, acetone, chloro- 
 form, benzene, carbon disulphide and carbon tetrachloride, all 
 more or less dissolve fatty substances, notably the epidermic fats; 
 they accordingly have a cleansing and drying effect. I habitually 
 employ a few drops of benzin to cleanse the surfaces for examination. 
 
 These bodies likewise dissolve certain medicinal substances insol- 
 uble in water; by acting as vehicles they favor their action, permit- 
 ting them to penetrate down to the vicinity of the active layers of 
 the epidermis. But the irritative effect of solutions of this kind 
 restricts their application to a few special cases. 
 
 Powders. — By virtue of their mere physical properties, powders 
 increase the surface of evaporation and thereby exert a cooling, 
 drying action and relieve congestion. These effects increase with 
 their power of absorption. 
 
 The first rank from this point of view belongs to a f ossiferous 
 earth, known in France as " ceyssatite;" this is a natural product, 
 an earth composed of the silicious shells of foraminifera; a small 
 quantity of this powder suffices to transform a salve into a thick 
 
THERAPEUTIC NOTES 715 
 
 paste. The only objection to ceyssatite is that it is not readily 
 obtainable. [It is identical with Unna's Kieselgur or Terra silicea.] 
 Other so-called inert powders, both mineral and vegetable, have the 
 same properties, but to a lesser degree. 
 
 The mineral powders chiefly used are the following: talc, zinc 
 oxide, the carbonates of calcium, magnesium or bismuth, the sub- 
 nitrate of bismuth, kaolin or bolus alba; vegetable powders: corn, 
 rice or potato starch, various flours, lycopodium. It must be kept 
 in mind that starches and flour have the disadvantage of swelling 
 on exposure to moisture and of undergoing fermentation. 
 
 In order to render powders more adherent, they can be incor- 
 porated in weak proportion with lotions or better in larger propor- 
 tion with glycerinated or mucilaginous fluids, forming watery pastes. 
 [The popular calamine lotion belongs to this class of powders in 
 suspension in a watery fluid. Calamine is (nowadays) an artificial 
 carbonate of zinc stained a pink color; a convenient formula is: 
 1$ — calaminse prsep., 3.0; zinci oxidi, 4.0; glycerini, 1.0; aq. rosse, 
 100.0 M. Various soluble drugs may be incorporated in this mix- 
 ture; e. g., boric or salicylic acid, resorcinol, etc., or other insoluble 
 powders added, e. g., sulphur precip.] 
 
 Glycerine. — Glycerine, which when pure is very hygroscopic and 
 is miscible with water in any proportion, and its derivate, glycerite 
 of starch, are less emollient and less cooling than watery solutions; 
 on the other hand, when employed in dressings, they are superior to 
 wet-dressings in that they reduce the risk of auto-inoculation with 
 pyococci. Compared to fatty bodies they are less heating, but lend 
 less suppleness to the horny layer. 
 
 Glycerite of starch with an addition of inert powders makes a 
 very good paste which can be mixed with various active remedies 
 and is easily removed by washing. 
 
 Watery Pastes. — These are mixtures of equal parts of powder and 
 dilute glycerine. They are easily prepared, convenient and clean 
 in use ; moreover, not expensive, so that they are liked by patients 
 and deserve their growing popular favor. They are applied in a thin 
 layer, with a flat brush, left to dry for an instant, then covered with 
 a generous sprinkling of talc; no dressing is necessary; they may be 
 removed by washing with water. 
 
 The simplest type of watery paste is composed of equal parts of 
 zinc oxide, talc, glycerine and water. The talc may be replaced by 
 calcium carbonate or starch. A number of liquid or powdery 
 medicinal agents can be introduced into these pastes, such as 
 ichthyol, coal-tar emulsion, lead-water, borated water, lime-water, 
 precipitated sulphur, etc., care being taken to observe that the pro- 
 portion of glycerinated fluid and powder remains the same. The 
 addition of § per cent, of gum Arabic renders these pastes more 
 
 
716 APPENDIX 
 
 adherent; the addition of 5 to 10 per cent, of alcohol makes them 
 more drying. 
 
 The various watery pastes are especially adapted to the treat- 
 ment of the inflammatory and pruritic non-oozing dermatitides. 
 
 Fatty Bodies. — The fatty or oily bodies, which serve for inunctions, 
 play an important part in dermatotherapy, lending themselves well 
 to lasting and extensive local applications. They adhere to the 
 epidermis and slightly penetrate it, making it supple, swelling the 
 horny cells and detaching the scales. But they prevent the evapor- 
 ation of the secretions and the cutaneous perspiration in proportion 
 to their impermeability to water, thereby acquiring a congestive 
 and heating effect. 
 
 In this respect, enormous differences exist between the various 
 substances designated as fatty bodies on account of their compo- 
 sition. In this group belong: (1) Fats properly speaking, solid, 
 pasty, or oily, of animal or vegetable origin (fresh or benzoinated 
 lard, beef-marrow, whale oil, cacao butter, sweet almond oil, olive 
 oil, castor oil, cod-liver oil), which are glycerine-ethers or triglycer- 
 ides. Fats admit the incorporation of only a very small proportion 
 of water; they are capable of saponification and turn rancid in the air. 
 (2) Hydrocarbons, such as the vaselines, petroleum, paraffins, etc.; 
 these are not at all miscible with water; they do not change on 
 exposure to the air. (3) Wool fats (adeps lame, lainine, lanoline 
 [eucerine] which are cholesterine ethers; large amounts of water 
 can be incorporated into them (over 300 per cent.), transforming 
 them into creams. The French Codex of 1908 designates as lanoline, 
 wool-fat mixed with water to a proportion of 25 per 100. 
 
 The consistence of the fatty bodies may be arbitrarily varied by 
 combining those which are liquid, such as the oils, or of slightly fluid 
 consistence, such as lard and vaseline, with more viscid fats, like the 
 wool-fats, or solid fats, like beef-marrow, spermaceti, cacao butter, 
 or even with wax or paraffin. The resulting mixture retains the 
 general properties of its constituents. 
 
 There are other additions, notably those of powders or water in 
 considerably proportion, which modify not only the consistence, but 
 also very notably the immediate effects of the fatty bodies. 
 
 Salves. — Salves are natural or combined fatty bodies into which 
 one or several medicinal substances has been incorporated. As 
 these salves are always more or less impermeable to the cutaneous 
 perspiration, they have a heating, congestive effect, as mentioned 
 above; but at the same time they favor the real and deep action of 
 the active substances contained in them. 
 
 Salve Sticks. — Mixed with wax, paraffin, etc., salves may be 
 moulded into sticks, which are easy to manipulate and very con- 
 venient. 
 
THERAPEUTIC NOTES 717 
 
 Pastes. — By mixing the fatty bodies with a considerable quantity 
 of powders (on the average, equal parts of fats and powders), fatty 
 pastes are obtained. These soften and protect the skin surface on 
 which they are applied; they moreover possess the essential property 
 of being porous, permeable to perspiration, consequently relieving 
 congestion. Medicinal substances incorporated into a paste have a 
 moderate action, intermediate between that of salves on the one 
 hand and of creams and watery pastes on the other. 
 
 Creams. — Creams are formed by an intimate admixture of fatty 
 bodies with a large proportion of water or of watery solutions. 
 
 The relative quantity of water contained in the different creams 
 is very variable; 17 per cent, in cold cream; 33 per cent, in "Galien 
 cerate;" 43 per cent, in "cucumber cream;" 50 per cent in oil- and 
 lime-water liniment. Mixtures of wool-fats and vaseline are best 
 adapted to the manufacture of creams very rich in water (up to 
 1000 to 100) and do not turn rancid. 
 
 Creams cannot serve for active treatment, but are cooling and 
 softening. 
 
 Milks, several varieties of which are offered in trade (notably the 
 milk of Sapolan, the collosols, etc.), are emulsions of hydrocarbons, 
 lanoline, etc., and possess analogous although mild properties. 
 
 Soapy salves are useful as cleansing agents. 
 
 Occlusive Dressings. — Zinc gelatine is permeable to perspiration 
 and has a protective action, relieving congestion and itching. 
 
 Plasters, sparadraps or epithems, are formed by some tissue or 
 fabric covered with a layer of a plastic substance of such consistence 
 as to adhere firmly to the skin. The older plasters, consisting of 
 litharge, lard and various resins, which are apt to crack and fre- 
 quently have an irritating effect, are now advantageously replaced 
 by plasters prepared with a base of lanolin or vaseline, caoutchouc 
 and a little wax. Practically all external dermato-therapeutic agents 
 may be incorporated into these plasters, in variable proportions. It 
 must be kept in mind that all plasters, being impermeable, prevent 
 evaporation and cutaneous perspiration, so that they have a heating 
 and congesting effect. 
 
 Varnishes soluble in water (caseine ointment, gelanthum and 
 analogous preparations) have not been adopted in current derma- 
 tological practice. [A varnish of ichthyol and water, equal parts, 
 is valuable in many acute erythematous conditions, e. g., acute 
 dermatitides, erysipelas, etc.] 
 
 Ether varnishes (collodion), acetone (filmogen) ["new-skin"] and 
 chloroform varnishes (traumaticine) are employed only in certain 
 special conditions. 
 
718 APPENDIX 
 
 After this brief review of the pharmaceutic forms under which 
 the medicinal agents used in dermato-therapy are employed, these 
 agents will now be considered as such, arranged by their therapeutic 
 indications. 1 repeat the reservations previously stated concerning 
 the value of this classification. 
 
 Where a series of simple or compound substances appear in the 
 same paragraph, they may be regarded as analogous; but they 
 differ necessarily among themselves by shades which I have not 
 always found it possible to indicate. 
 
 The somewhat complex combinations have been presented in the 
 form of prescriptions, sometimes signed with the name of their best 
 known author. It should be clearly understood, however, that there 
 is nothing binding about these prescriptions; the excipients have 
 been purposely varied, to serve as examples, so that a given excipient 
 may always be replaced by some other of analogous consistence and 
 the same physical properties. 
 
 The majority of the prescriptions are given on a basis of about 100 
 parts, as an aid to memory; it is left to the physician to estimate the 
 quantity of remedy required in a given case. 
 
 [It may be useful to remember that 25 grams of a soft ointment, 
 of the consistence of vaseline, is ample for a single inunction over 
 the entire cutaneous surface of an adult; twice that amount is 
 hardly enough to cover the surface with a firm paste like Lassar's.] 
 
 1. ANTIPHLOGISTICS. 
 
 Antiphlogistic, sedative, cooling and emollient treatment is em- 
 ployed in the acute dermaiitides in general, in the active erythemas, 
 eczema, etc. Cases in which it is indicated are therefore extremely 
 common. It comprises several procedures between which a selection 
 must first be made according to circumstances, but which are often 
 employed in combination or successively. 
 
 These procedures consist of the use, under different forms, of 
 water and watery solutions, especially to be recommended when 
 crusted surfaces have to be cleaned at the same time; of powders 
 and watery pastes; of creams, milks, or glycerites and more rarely, 
 of fatty pastes or salves. 
 
 Lotions {washes). — Preferable to simple boiled water is an infusion 
 of camomile flowers, lime- or elderblossoms, or a decoction of ele- 
 campane roots, marshmallow, etc., or some isotonic solution may 
 be used, such as physiological salt solution, or better the cytoplastic 
 solution of Professor Delbet (magnesium chloride, dry, 12.10, or 
 crystallized magnesium chloride 25.85, to one liter of water) with 
 which I have been especially well pleased of recent years. Weak 
 
ANTIPHLOGISTICS 719 
 
 antiseptic and astringent solutions may also be employed (§2). 
 Lotions should usually be applied hot and several times daily. 
 
 Sprays. — The above-mentioned solutions may be employed as 
 sprays, by means of a Richardson apparatus or vapor spray, repeated 
 several times daily. 
 
 Moist Occlusive Dressings. — These are used every day in derma- 
 tology even more than in surgery. 
 
 Moist dressings consist of compresses of sterilized gauze, soaked 
 in one of the above-mentioned infusions, decoctions or solutions, 
 well squeezed out so as to be merely damp, then applied so as to 
 cover widely the affected region; they are covered with an imper- 
 meable layer of rubberized cloth, oil-silk, or gutta-percha, with a 
 margin to spare on all sides; next, with a layer of cotton; the whole 
 is held in place by a bandage. These dressings should generally be 
 applied cold; they must be really occlusive and be renewed once or 
 twice in the twenty-four hours. [The Liq. aluminii acetatis diluted 
 with 10 to 15 parts of water is especially valuable for its astringent 
 and mildly antiseptic properties.] 
 
 Poultices. — On account of their mucilaginous consistence, these 
 are often better tolerated than moist dressings. They are prepared 
 as follows: Mix with two spoonfuls of cold water, a spoonful of 
 mashed potato or starch; slowly pour this dilution into a sauce- 
 pan containing eight spoonfuls of boiling water for the mashed 
 potato, not more than six spoonfuls for the starch, stirring to a 
 jelly; then spread on muslin, folding the borders over the mixture. 
 Linseed meal, the oil of which turns rapidly rancid, is not to be 
 recommended. Ready-made starch and other poultices are on the 
 market which only need to be softened in a little luke-warm water. 
 
 Poultices are applied cold or barely luke-warm and renewed two 
 or three times daily; it is not usually necessary to cover them with 
 an impermeable material. [Salicylic acid, one per cent., or boric 
 acid, 5 per cent., may advantageously be dissolved in boiling water 
 in preparing these poultices.] 
 
 Baths. — Aside from local warm baths, which are indicated for 
 example in lymphangitis, general baths of pure water, baths of starch 
 water, lime blossom decoctions, gelatins, etc., are oftener harmful 
 than useful in erythemas, urticarias, acute eczemas and especially in 
 the presence of a complicating pyodermatitis. 
 
 Alcohol Dressings. — This therapeutic procedure, inherited from 
 Ambroise Pare, is not sufficiently appreciated. It is highly useful 
 
720 APPENDIX 
 
 and may serve at the onset to abort furuncles and carbuncles, 
 lymphangitic abscesses, bvbos, etc. The compresses should be soaked 
 in 9o° or 90° alcohol, no weaker; covered with impermeable material 
 and renewed every twelve or twenty-four hours, according as the 
 occlusion has been more or less perfect. 
 
 Powders. — It has been previously stated that absorbent or inert 
 powders are far from being useless; they have on the contrary a 
 cooling, drying action and [by increasing the surface for evaporation] 
 evidently relieve congestion. 
 
 Various powders are often combined and coloring substances may 
 be added to the mixture if desired by the patient, or they may be 
 rendered slightly antiseptic or antipruritic. 
 
 Two examples follow, meeting each of these two indications: 
 
 PULVIS CUTICOLOR (UNNA). 
 
 Rice starch 40.0 gr. 
 
 Zinc oxide 25.0 
 
 Magnesium carbonate 20.0 
 
 Bolus alba 12.5 
 
 Bolus armenian 2.5 
 
 COMPOUND POWDER. 
 
 Talc, venet 40.0 gr. 
 
 Calcii carbonat. 
 Magnesii carbonat. 
 
 Zinci oxidi aa 20.0 
 
 Ichthyol or gomenol 1 to 2 . 
 
 Ointments. — The only ones usually to be recommended in cases 
 of acute dermatitis are watery pastes, creams, and sometimes 
 glycerites, etc. 
 
 Watery pastes may be simple or compound: 
 
 SIMPLE WATERY PASTES. 
 
 Zinc oxide, talc, glycerin, water equal parts 
 
 or 
 
 Zinc oxide, calcium carbonate, glycerin, lime-water . . equal parts 
 
 COMPOUND WATERY PASTES. 
 Zinc oxide, 
 
 Starch aa, 25.0 gr. 
 
 Glycerin, 
 
 Water aa 20.0 
 
 Ichthyol 10.0 
 
 Gum Arabic, powd 0.5 
 
 These pastes are applied with a flat brush, left to dry for half a 
 minute, then covered freely with talc. 
 
 Among the creams, namely mixtures of fatty bodies and a large 
 
ANTIPHLOGISTICS 721 
 
 proportion of water, may be quoted: cold cream, Galien cerate, 
 cucumber cream, lime- and oil-liniment (almond oil and lime-water 
 in equal parts). I prefer the following creams, because they do not 
 turn rancid: 
 
 VASO-LANOLINE. 
 
 Petrolati 10.0 gr. 
 
 Lanolini anhydr 5 . gr. 
 
 Aq. rosae, 
 
 Aq. lauro-cerasi, 
 
 Aq. aurant. flor aa 5.0 
 
 Triturate well, adding the waters drop by drop. If lime-water be substituted for 
 oneof the'scented waters the emulsion is facilitated and keeps better. 
 
 CREAM OF STEARATE OF SODA. 
 
 Liq. sodse 5.0 
 
 Ac. stearic 25.0 
 
 Glycerin 75.0 
 
 Aq. rosffi 120.0 
 
 Heat and mix ; solidify by cooling, then heat again, stirring vigorously. 
 
 QUININE VASOLANOLINE (PREVENTIVE OF SOLAR ERYTHEMA). 
 
 Petrolati 10.0 
 
 Lanolin anhydr 5.0 
 
 Aqueous solution of neutral bromhydrate of quinine 1 to 15 . 15.0 
 Apply before exposure to the sunlight and powder with 
 
 Talcum 15.0 
 
 Basic quinin sulphate 1.0 
 
 Certain oils (pyroleol of Edet, phlyctol of Robert and Carriere, 
 which are compound purified and sterilized oils of melilotus), applied 
 in dressings, have a soothing and truly analgesic action, valuable 
 in burns, phagedena and gangrenous ulcers. 
 
 Starch glycerite, Sapolan cream, soapy salves and "diadermine" 
 which is a glycerite of stearates, can sometimes substitute the 
 creams. 
 
 Milks, Sapolan or others, which are emulsions of lanoline and 
 hydrocarbons, are cooling and much liked by patients. 
 
 In the acute dermatitides, pastes and especially salves should be 
 avoided; they are often very badly tolerated; fresh lard, however, 
 is frequently very soothing. 
 
 When the inflammation is plainly subacute, simple pastes or 
 pastes with a slight admixture of ichthyol may prove serviceable. 
 
 LASSAR'S PASTE. 
 Zinc oxid, 
 Starch, 
 Vaselin, 
 Lanolin aa equal parts 
 
 SOFT PASTE OF UNNA. 
 Zinc oxide, 
 Prepared chalk, 
 Linseed oil, 
 
 Lime-water aa equal parts 
 
 46 
 
APPENDIX 
 
 GLYCEROL ICHTHYOL PASTE. 
 
 Neutral glycerite of starch 70.0 
 
 Kaolin, 
 
 Magnesium carbonate aa 15.0 
 
 Ichthyol 3 to 5 . 
 
 ZINC, OIL AND ICHTHYOL. 
 
 Olive oil washed with alcohol 40.0 
 
 Zinc oxide 60.0 
 
 Ichthyol 1 to 3 . 
 
 2. WEAK ANTISEPTICS AND ASTRINGENTS. 
 
 It has come to be understood, especially of recent years, that 
 antiseptics applied for the purpose of killing the microbes or inhibit- 
 ing their growth, are at the same time injurious to the tissues, the 
 more so in proportion to their activity. It is therefore not practi- 
 cable to disinfect a wound or an infected cutaneous surface all at 
 once by means of a strong antiseptic. In order to attain this end, 
 or at least to favor the organism in its fight against the infecting 
 agents and thereby to assist the cure, only so-called cytophylactic 
 substances should be employed, namely substances which spare the 
 cells; or mild antiseptics as slightly injurious to the body tissues 
 as possible. 
 
 Lotions and Sprays. — In the majority of the cases, it is advisable 
 in my opinion not to make an excessive use of lotions. When there 
 is reason, however, for cleansing a wound, an ulcer, or an infected 
 dermatosis, one of the following watery solutions may be employed: 
 the classical borated water (boric acid 4 : 100), boricine, or biborate 
 of soda obtained by the action of boric acid on borax, in equal parts 
 and hot (4 to 10 : 100), dilute peroxide water, weak carbolized water 
 (phenol 1 : 100), resorcinated water (resorcinol 1 :200), phenosalyl 
 or a solution of phenol salicylate (1 : 200), decoctions of cinchona, 
 oak bark or other astringent, tannic acid decoctions, and finally a 
 solution of lead subacetate [Liq. plumbi subacetat. dil.]. 
 
 Matchless, in my opinion, is Alibour water [copper and zinc 
 sulphate in camphorated water] which renders me every day the 
 most valuable service and Labarraque's fluid, or the officinal 
 solution of soda hypochlorite, which should be diluted with water to 
 4 to 10 times its volume; or better still, Dakin's solution. Burrow's 
 solution [Liq. alumin. acetat.] is extensively used abroad. 
 
 ALIBOUR WATER (PYODERMATITIDES). 
 
 ( lupric sulphate 2.0 
 
 Zinc sulphate 7.0 
 
 Camphor water saturated 300.0 
 
 Filter; for use dilute a tablespoonful or two to a glass of water. 
 
WEAK ANTISEPTICS AND ASTRINGENTS 723 
 
 burrow's solution (oozing dermatitides) . 
 
 Alum . . . 1.0 
 
 Plumbic acetate 5.0 
 
 Water 100.0 
 
 Not to be filtered; shake before use and dilute with 5 to 20 volumes of water. 
 
 [Burrow's solution is best prescribed as liq. alumini acetatis; diluted before use 
 with 10 to 20 volumes of water.] 
 
 Moist Antiseptic Dressings. — All the above enumerated solutions 
 may be employed for moist occlusive dressings, of course in their 
 weakest solutions. The only exception is Alibour water, which is 
 inefficient in dressings, in my experience. The question of the 
 aseptic, antiseptic and other dressings will be taken up later on. 
 
 Baths. — Local baths, with mild antiseptics, may be useful in the 
 acute dermatitides and lymphangitides of the limbs and of the penis. 
 For general baths, I make use only of zinc sulphate (20 to 40 grams 
 for a full bath) in the generalized pyodermatitides. 
 
 Solutions for Painting, Touching, etc. — Although they must not be 
 abused, it may be useful to know the preparations which may be 
 employed in ulcers, atonic wounds, folliculitis, herpes, etc. Tincture 
 of iodine is really used to excess at the present time, but is never- 
 theless valuable for painting, as well as iodo-acetone (2 to 5 : 20) 
 or iodo-chloroform (1 to 15), for aborting boils and in the epidermo- 
 mycoses. The Lugol-Gram solution (iodine, 1 gr. KI, 2 gr., water 
 300 gr.) serves for tuberculous or mycotic ulcers; iodoform ether 
 (1 : 20), guaiiacol oil (equal parts), gomenol oil (5 to 20 : 100), in 
 tubercidous or sluggish idcers; camphorated iodoform oil (3 : 10 : 100) 
 makes a good dressing for soft chancres and bubos (Dinet). Cam- 
 phorated alcohol (1 : 100), borated alcohol (1 : 16), alcohol with 
 resorcin (1 : 50) or alcohol with thymol (1 : 100) and borated glycer- 
 ine (1 : 100) or carbolized glycerine (1 : 50) are useful for touching 
 or brief application during a few minutes in herpes and folliculitides 
 such as furuncles of the auditory meatus, etc. 
 
 Gargles {stomatitis and buccal ulcerations). — Dilute Labarraque's 
 solution (50 : 1000), hydrogen peroxide water, "Neol" (1 : 10), a 
 few drops of tincture of ratanhia or myrrh in a glass of water; 
 decoction of snake-weed (bistorta) (20 : 1000); astringent gargles 
 with alum, sodium borate, potassium chlorate; chloral hydrate 
 (1 to 1.50 : 100), etc., with glycerine or honey. 
 
 A soapy tooth-paste should also be recommended, containing 
 sodium borate or extract of ratanhia, etc. 
 
 GARGLE. 
 Sodium chlorate, 
 Sodium salicylate, 
 
 Sodium bicarbonate aa 2.0 
 
 Honey 75.0 
 
 Water 225.0 
 
724 APPENDIX 
 
 TOOTH-PASTE. 
 
 Soap 10.0 
 
 Carbonate of lime, 
 
 Tricalcic phosphate aa 20. 
 
 Carmin 0.1 
 
 Oil of peppermint 3.0 
 
 Collutories. — Iodized glycerine (iodine and carbolic acid aa 0.25, 
 KI, 1.0; glycerine 50) in buccal ulcerations; borated glycerine 
 (4 :30); or borated honey (5 : 20), For thrush; honey with alum 
 (5 :30). 
 
 Powders. — Iodoform, pure or camphorated (5 : 100) and its sub- 
 stitutes: iodol (iodopyrol), diiodoform (C 2 I 4 ), aristol (diiodothymol 
 or ihyrrvoliodide of Poulenc; europhen (butocresiol) , airol (oxyiodo- 
 gallate of bismuth or alphaform); dermatol or officinal bismuth 
 subgallate; xeroform (tribromophenate of bismuth or sigmaform); 
 chemically pure methylene blue; tannoform (formotan); subearbon- 
 ate of iron; cinchona, etc. 
 
 To these more or less antiseptic powders which can be prepared 
 in mixtures, as will be shown by an example, Vincent's powder has 
 been added since 1017, which is very efficient through the nascent 
 chlorine given off from it and but slightly irritant; it acts as a 
 powerful preventive of infection on recent jagged wounds; more- 
 over it yields good results in infected wounds and ulcers of variable 
 character and even, in my experience, in soft chancre and chancroidal 
 bubo. 
 
 COMPOUND POWDER OF J. LUCAS CHAMPIONNIERE. 
 
 Iodoform, 
 Benzoin powder, 
 
 Cinchona powder aa, 100.0 
 
 Magnesium carbonate, 
 
 01. eucalyptus 12.5 
 
 Vincent's powder. 
 
 Hypochlorite of lime 10.0 
 
 Boric acid, dry 90.0 
 
 Powder separately, mix well and preserve in a dry dark-glass bottle. 
 
 Ointments. — Creams, glycerites, pastes or salves may be employed, 
 in different cases, salves being the most active; one or several of 
 the following remedies are incorporated: Yellow oxide of Hg. (5 to 
 10 : 100); white precipitate (1 to 10 : 100); camphor (1 : 100); 
 boric acid (5 to 10 : 100); salicylic a?id (1 to 2 : 100); resorcinol 
 (1 to 2 : 100); naphthol (0.5 to 1 : 100); or various essential oils: 
 gomenoloil (5 to 50 : 100). 
 
 YELLOW SALVE (PYODERMATITIDES) . 
 Yellow oxide of mercury, 
 
 Oxide of zinc aa, 10.0 
 
 Resorcinol, 
 
 Salicylic acid aa, 1.0 
 
 Vaselin 78.0 
 
WEAK ANTISEPTICS AND ASTRINGENTS 725 
 
 ICHTHYOLATED YELLOW PASTE (iMPETIGENIZED ECZEMA). 
 
 Ichthyol, 
 
 Yellow oxide of mercury aa 5.0 
 
 Resorcinol, 
 
 Salicylic acid aa 1.0 
 
 Oxide of zinc, 
 
 Talcum aa 20.0 
 
 Vaselin 48.0 
 
 Ichthyolated Lassar's paste (5 per cent.) with an addition of 
 resorcinol (1 : 100) or salicylic acid (1 : 100) is extremely useful 
 and in daily use; the nature of the fats or powders which enter 
 into the composition of the excipient may be arbitrarily changed, 
 incorporating at will reducing agents, keratoplastic or antipruritic 
 agents, etc. 
 
 Starch glycerite with boric acid (100 : 10) is the topical applica- 
 tion of choice in the treatment of boils, carbuncles and the pyoder- 
 matitides in general (Gallois). 
 
 Cold cream is a favorite vehicle for white precipitate (1 to 10: 100). 
 with or without addition of tannin (1 to 5 : 100). 
 
 Borated vaseline is in common use as a weak antiseptic salve. 
 It is also employed for the nasal fossa?. 
 
 gomenol-resorcinol salve (rhinitis, folliculitis of the 
 
 nostrils) . 
 
 Boric acid 10.0 
 
 Resorcinol 2.0 
 
 Gomenol 1.0 
 
 Vaselin 50.0 
 
 YELLOW EYE-SALVE (BLEPHARITIS, IMPETIGINOUS CONJUNCTIVITIS). 
 
 Yellow oxide of mercury 0.15 
 
 Guaiacol 0.05 
 
 Lanolin 6.0 
 
 Vaselin oil 10.0 
 
 Varnishes. — Antiseptic varnishes find their indications in certain 
 dermatitides with an intact epidermis (lymjihangitis, erysipelas); 
 in these cases, thigenol, pure ichthyol or glycerinated liquid thiol 
 (fluid thiol, 85; glycerine, 15) are serviceable; on the other hand 
 as occlusives (fissures, rhagades, ulcerations of mucous membranes), 
 use can be made of complex varnishes composed of various 
 resins and balsams dissolved in alcohol or ether, which are generally 
 found ready-made in the drug stores; such as Baume de Com- 
 mandeur (Codex); steresol (Berlioz, Grenoble); adhesol (Leclerc). 
 Varnishes having an aseptic action through their physical properties 
 will be discussed later on. 
 
726 API'EXDIX 
 
 ■ I. STRONG ANTISEPTICS. 
 
 The statements made at the beginning of the preceding paragraph 
 suggest that the indications for strong antiseptic agents are rare 
 and limited. 
 
 The solutions and mixtures to be indicated in the following must 
 under no circumstances be employed for dressings, as they would be 
 too irritating and even caustic. They have to be reserved for washes, 
 touching or painting. 
 
 Watery Solutions. — Bichloride of mercury or corrosive sublimate 
 (1 to 2 : 1000); biniodide of mercury (1 : 1000); cyanide of mercury 
 2 to 5 : 1000; oxy cyanide of mercury (5 : 1000); strong carbolized 
 water (phenol 5 : 1000); "microcidine" or naphtholate of sodium 
 (3 to 5 : 1000); strong hydrogen peroxide water (12 to 20 volumes) 
 " lusoform," "aniodol," or watery, alcoholic or glycerinated solu- 
 tions of formol (0.25 to 1 : 1000)'. 
 
 Various Solutions. — Tincture of iodine; iodized acetone (1 to 3 : 10 
 camphorated naphthol (2 : 1); camphorated phenol (equal parts); 
 camphorated salol (3:2). 
 
 menctere's fluid (lacerated wounds, ulcers, etc.). 
 
 Iodoform, 
 Guaiacol, 
 
 Eucalyptol, 
 
 Bals. Peruv aa 1.0 
 
 Alcohol 10.0 
 
 Ether 100.0 
 
 To be used as a spray or for painting. 
 
 CALOT'S COMPOUND SOLUTION (TUBERCULOUS ULCERATIONS AND 
 COLD ABSCESSES). 
 
 Guaiacol 1-0 
 
 Creosote 2.0 
 
 Iodoform 9.0 
 
 Camphorated naphthol 20.0 
 
 Ether, 
 
 Olive oil (sterilized) aa 34.0 
 
 Ointments. — The following two salves enjoy a certain popularity: 
 
 RECLUS' SALVE (SLUGGISH ULCERS) MODIFIED BY BROCQ AND II. PIED. 
 
 Phenol crystal, 
 
 Salicylic acid aa 1.0 
 
 Resoreinol 2.0 
 
 Camphor, 
 
 Antipyrin iia 5.0 
 
 Bals. Peruv 6.0 
 
 Vaselin 80.0 
 
 Dissolve the first four substances in a little alcohol and glycerin; dissolve the 
 antipyrin in its own weight of water; then triturate the whole in a mortar. 
 
Antipruritic Agents And local Anesthetics 727 
 
 OINTMENT OF LUCAS-CHAMPIONNIERE (BURNS). 
 
 /3-Naphtholate of soda 0.3 
 
 Oil of thyme, 
 
 " geranium, 
 
 " verbena, 
 
 " origanum aa gtt. xv 
 
 Vaselin 100.0 
 
 4. ANTIPRURITIC AGENTS AND LOCAL ANESTHETICS. 
 
 For the local treatment of pruritus, a series of procedures and 
 remedies may be utilized. 
 
 Watery Solutions. — These are usually more efficient when hot, 
 although sometimes they act better luke-warm or cold. Decoction 
 of elecampane root (20 : 1000); bran water; infusion of chamomile 
 blossoms (20 : 1000) or lime-tree flowers (10 to 15 : 1000); an 
 infusion of coca leaves (10 to 20 : 1000); lime-water; cherry-laurel 
 water; chloral hydrate (2 to 4 : 100); Labarraque's solution (20 
 to 50 : 100); phenol (1 to 5 : 100); saponin coal-tar (10 to 30 :100); 
 sapolan milk, collosol with oil of cade or cod-liver oil, etc. [Liq. picis 
 alk. or Liq. carbonis deterg. 10 : 100.] 
 
 Baths. — These are often badly tolerated. Starch or bran baths 
 are sometimes prescribed, with an addition of vinegar (1 liter) ; or 
 baths of lime-tree flowers (1 kilo); finally, gelatine baths (250 to 
 500 gr. of gelatine, soften in cold water, dissolve while heating and 
 pour into bath). 
 
 Various Solutions. — For painting or touching, the following are 
 employed: Camphorated alcohol (1 : 10), or camphorated brandy 
 (1 : 40), or camphorated chamomile oil (1 :10); resorcin alcohol 
 (2 to 5 : 100); menthol alcohol (1 to 2 : 100); or mentholated oil of 
 vaseline (1 to 2 : 100); carbolized glycerine (phenol 5, water and 
 glycerine, aa 50); alcoholic solutions of silver nitrate (3 to 10 : 100); 
 lemon juice. 
 
 Especially advantageous are the alcoholic solutions of thymol 
 (1 : 200), of carbolic acid (1 : 100), of coal-tar emulsion (5 to 10: 1000), 
 to which castor oil or glycerine (5 to 10 : 100) are added to prevent 
 their too rapid drying; cover with powder or a watery paste. 
 
 ANTIPRURITIC SOLUTIONS. 
 Vinegar, 
 Camphorated alcohol, 
 
 Aq. lauro-cerasi ■ aa 100.0 
 
 Glycerin 50.0 
 
 Dilute with 4 to 10 parts of water. 
 
 Cocain muriate, 
 Chloral hydrate, 
 
 Resorcinol aa 1.0 
 
 Glycerin 3.0 
 
 Alcohol 20.0 
 
 Aq. lauro-cerasi 30.0 
 
 Water 44.0 
 
728 APPENDIX 
 
 Ointments. — The application of a fatty substance on a pruritic 
 region sometimes suffices to bring considerable relief to the patient; 
 fresh lard, cerate or pure vaseline may serve for this purpose; the 
 preference is often accorded to sapolan, naphtalan, pure cod-liver 
 oil, in compound salves, or better in the form of collosol. 
 
 Needless to say, it is often very advantageous to incorporate one 
 or several of the antipruritic substances with the salves or pastes. 
 Tse is frequently made of starch glycerite with tartaric acid (5: 100), 
 or a mentholated oil with chloroform (camphorated oil of chamomile, 
 100, chloroform 2 to 5, menthol 1.) 
 
 Ethyl para-amido-benzoate (anesthesine or benzocaine of Poulenc) 
 is employed (10 to 30 : 100) in a lanolin cream mixed with alcohol or 
 olive oil (10 to 30 : 100) ; or also in a mucilage of gum Arabic. Ortho- 
 form (orihocaine) should be rejected on account of the severe erup- 
 tions and intoxications which it may cause. 
 
 SALVE. 
 
 Menthol 1.0 
 
 Chloral hydrate, 
 
 Camphor aa 5.0 
 
 Lanolin 35.0 
 
 Vaselin 50.0 
 
 PASTE. 
 
 Menthol 0.5 
 
 Phenol 1.0 
 
 Salicylic acid 2.0 
 
 Tumenol 5.0 
 
 Lassar's paste 90.0 
 
 COD-LIVER OIL SALVE. 
 
 Cod-liver oil 5.0 to 30.0 
 
 Olive oil 5.0 to 25.0 
 
 White wax 5.0 
 
 Paraffin 8.0 
 
 Aq. rosae, 
 
 Aq. lauro-cerasi . aa 10.0 
 
 Occlusive Dressings. — Undoubtedly the mere fact of protecting 
 the diseased surfaces from the air represents a valuable measure for 
 the control of pruritus. Salves and pastes evidently owe to this a 
 considerable share of their efficiency. Poultices with starch, moist 
 dressings and properly applied cotton wraps likewise secure good 
 occlusion, provided the affected surfaces are not too extensive. 
 "Zinc gelatin," which is applicable to large surfaces, if desired, is 
 still more practical; here follows the fundamental formula and a 
 modified formula so as to render the gelatin harder in the warm 
 season of the year: 
 
 Gelatin 15 or 30 gr. 
 
 Zinc oxide 15 or 10 gr. 
 
 Glycerin 25 or 30 gr. 
 
 Water 45 or 30 gr. 
 
ANTIPRURITIC AGENTS AND LOCAL ANESTHETICS 729 
 
 The mass is liquefied in the water-bath, applied with a flat brush, 
 then while the coating is still viscid, the surface is dusted with ab- 
 sorbent cotton which adheres to it and gives it the appearance of 
 swan-skin. A zinc-gelatin covering may be left in place for several 
 days; it is removed by stripping or by means of warm water. 
 
 With this zinc-gelatin, ichthyol or other active substances may be 
 incorporated; it is preferable to apply these substances by painting 
 them on first, after which the surface is covered with the gelatin. 
 
 Varnishes and Plasters. — The entire series of tars and analogous 
 substances may serve as a siccative coating, either in the natural 
 state (coal-tar, vegetable-tar, ichthyol, thiol, tumenol, thigenol, etc.), 
 or in the form of extracts, or ether and alcoholic or various other 
 solutions. 
 
 The ordinary plasters can nearly all be utilized for the treatment 
 of localized pruritus. For this purpose, use is made especially of 
 zinc oxide plaster, resorcinol or phenol plaster, red oxide, or cod- 
 liver-oil plaster, etc. 
 
 When treating pruritus and prurigo by topical medication, one 
 must never omit adding advice concerning hygiene, hydrotherapy, 
 the employment of electricity under various forms, hot air, hyper- 
 tonic sera, etc. 
 
 Local Anesthesia. 
 
 This is very exceptionally indicated in the cutaneous neuralgias 
 or dermatalgias (zona, herpes, etc.); in such cases, hot poultices, 
 or ichthyol, guaiacol, carbolized and other solutions indicated above 
 and painted on, are usually sufficient. 
 
 To spare the patient the pain of certain small operations such 
 as scrapings, scarifications, rather extensive biopsies (tuberculosis 
 verrucosa, lupus, proliferations, tumors), there are several methods. 
 The quickest is freezing with a jet of ethyl chloride, which has 
 replaced the bag of salted ice, stypage with methyl chloride, etc. 
 Much more complete and durable is anesthesia by injection of a 
 solution of cocaine chlorhydrate (| to 2 : 100) locally or along the 
 course of the regional nerves (fingers, penis, etc.), the patient must 
 have eaten and be in the recumbent position; it is advisable not to 
 exceed the dose of 0.02 at the head, 0.05 elsewhere. The addi- 
 tion of a few drops of adrenalin or of carbolic acid (chlorhydrate 
 of cocaine 2, phenol cryst. 0.50 to 1.0, water 100) favors anesthesia; 
 Schleich in his infiltration method showed that very weak concen- 
 trations are sufficient (chlorhydrate of cocaine, 0.10 to 0.20, sodium 
 chloride 0.20, water 100). Less toxic than cocaine are allocaine, 
 stovaine, etc.; I usually employ a solution of novocaine to which 
 adrenalin is added just before use (novocaine 0.50 or 1.0, water 
 
7: 10 APPENDIX 
 
 100, adrenalin „'„,], 10.0 to 25.0). It is essential after injecting 
 analgesic agents to wait at least fifteen or twenty minutes before 
 operating. 
 
 Bonin's mixture (chlorhydrate of cocaine, menthol, carbolic acid, 
 aa equal parts) is very efficient when painted over mucous mem- 
 branes, ulcers and excoriated surfaces. 
 
 5. CLEANSING AND KERATOLYTIC AGENTS. 
 
 This group of therapeutic agents is applicable to the scaly or 
 crusted dermatoses and to the keratoses. 
 
 Baths. — To cleanse large surfaces, soapy baths may be utilized 
 or alkaline baths (sodium carbonate 60 to 250 gr.) or sulphurous 
 baths (hepar sulphuris 60 to 100 gr.). Vapor baths and dry air baths, 
 at 70° or 80° (160°-175° F.) or over, act also through the sweating 
 produced by them. 
 
 Lotions. — Any soap with a soda base may be used for soapy washes. 
 In city practice, patients prefer a prescription of some medicated 
 soap; ichthyol, lanolin, salicylic acid, tar, sulphur, naphthol soaps, 
 etc., are the most commonly used. 
 
 Potash soaps, which are soft, are more keratolytic than soda 
 soaps. Black soft soap is uninviting; but a white odorless potash 
 soap can be made. 
 
 The alkalimetric titration of the commercial soaps varies in con- 
 siderable proportions. It may prove advantageous to render them 
 less irritating by transforming them into super-fatted soaps. 
 
 WHITE POTASH SOAP (VICARK)). 
 
 Cocoanut oil 200 . 
 
 Caustic potash, c.p 70.0 
 
 Water 600.0 
 
 Saponify hot and boil down to 500. To make this soap super-fatted, add stearin 
 and water, aa 20, to each 100. 
 
 LIQUID SUPERFATTED SOAP (FOR SURGICAL USE). 
 
 Green soap, 
 
 Castile soap aa 20 . 
 
 Olive oil 17.0 
 
 Oil of geranium or lemon q. s. 
 
 Water 1000.0 
 
 Filter. 
 
 A decoction of quillaya (50 : 1000), quillaya extract and saponine 
 are preferable to soaps for the cleansing of the scalp. 
 
 Gentle rubbing with a wad of absorbent cotton moistened with 
 alcohol, ether, or better with benzine, very efficiently cleanses the 
 skin. 
 
CLEANSING AND KERATOLYTIC AGENTS 73 1 
 
 An excellent measure for cleansing a cutaneous surface covered 
 with crusts and scales consists in applying moist dressings or a 
 poultice during several hours. 
 
 Ointments. — A simple application of vaseline, almond oil, lard, 
 starch glycerite, a stearate such as diadermine, etc., often suffices 
 for the softening and detachment of the scales. For the scalp, beef 
 marrow or mixtures of fats are in favor, such as: 
 
 Cocoa butyr 30 
 
 Almond oil 70 
 
 01. rosse gtt. i 
 
 It is sometimes advantageous to make inunctions with a soapy 
 foam which is allowed to dry upon the skin (kerosis, acne). Soapy 
 ointments are very practical and can be employed on the scalp, on 
 account of the facility of cleansing with a wad of cotton moistened in 
 water. 
 
 SOAPY SALVE. 
 Powd. soap, 
 
 Lard aa 40.0 
 
 Almond oil 20.0 
 
 01. geranii gtt. iv 
 
 Heat the fats to 150° C. (302° F.) before introducing the soap powder. 
 
 SOAP SALVE (CARLE AND BOTTLED). 
 
 Lard 50.0 
 
 Potash 17.5 
 
 Water 300.0 
 
 Alcohol 10.0 
 
 Lanolin 20.0 
 
 Boil down to 120. 
 
 With these salves may be incorporated a large number of the 
 usual medicinal substances, notably sulphur, but not bodies which 
 are incompatible with alkalis, such as pyrogallol, chrysarobin, acids 
 in general, mercurial salts, etc. 
 
 Soft soap in inunctions has a very powerful cleansing action (lupus 
 erythematodes , pityriasis versicolor) ; but it is very irritating and its 
 effects must be watched. 
 
 Salicylic acid is the keratolytic agent par excellence. In weak 
 dosage (1 : 100), it figures in many pastes or salves as a mordant 
 and antipruritic agent; in stronger dosage (5 : 100) in vaseline, it 
 constitutes the most habitually used detersive agent (psoriasis, 
 ichthyosis, keratosis pilaris); in benzoinated lard and castor oil 
 (5 : 200), especially when immediately covered with an imper- 
 meable tissue, or in the form of an ointment or varnish, it displays 
 its maximum activity (keratoderma, circumscribed hyperkeratoses). 
 
 Acetic acid and lactic acid also have a keratolytic action. 
 
732 APPENDIX 
 
 Resorcinol, which in weak doses acts as a keratoplasty agent, is on 
 the contrary in strong doses (5 to 50 : 100) an excellent detersive 
 and even exfoliating agent. The last named property is utilized 
 in the following preparations which are destined to serve for exfoli- 
 ation cures {acne, kerosis, flat warts, pigmentations). Resorcine may 
 be combined with soft soap. 
 
 MIXTURE FOR FLAT WARTS. 
 Arctic acid (glacial), 
 
 Lactic acid aa 10.0 
 
 Precipitated sulphur 20.0 
 
 Glycerin 40.0 
 
 Apply cautiously; an analogous mixture may he made with ac. salicyl. or with 
 phenol. 
 
 KERATOLYTIC SALVE FOR SEVERE ACNE OF TRUNK (BROCQ). 
 
 Resorcinol, 
 
 Camphor aa 10.0 
 
 Potash soap 15.0 
 
 Precipitated sulphur 30.0 
 
 Creta prep 5.0 
 
 Vaselin 30.0 
 
 Apply for five, then ten, then fifteen minutes before a hath. 
 
 EXFOLIATING PASTE. 
 
 Resorcinol 40.0 
 
 Zinc oxide 10.0 
 
 Kaolin 5.0 
 
 Benzoated lard 25.0 
 
 Unna [modified]. 
 
 EXFOLIATING MIXTURE. 
 
 Resorcinol 20.0 to 30.0 
 
 Potash soap, 
 
 Sulphur aa 20.0 
 
 Spts. lavandulse 30.0 to 40.0 
 
 Plasters and Varnishes. — In the case of circumscribed keratoses and 
 verrucosities, potash soap plasters, and especially salicylated plasters, 
 render excellent service. Collodium is also frequently employed. 
 
 COLLODIUM FOR CORNS. 
 
 Collodii flex 10.0 
 
 Absolute alcohol 6.0 
 
 Ether, sulph 4.0 
 
 Salicyl. acid 2.0 
 
 Ext. canabis Indica 1.0 
 
 COLLODION FOR PAPILLARY WARTS. 
 
 Collodii flex 10.0 
 
 Absolute alcohol 6.0 
 
 Ether sulph 4.0 
 
 Ac. salicyl 2.0 
 
 A(". lactic , . 1.0 
 
BLEACHING AGENTS 733 
 
 6. BLEACHING AGENTS. 
 
 Bleaching agents are employed in the treatment of hyperchromias, 
 ephelides, chloasma, etc., and of hypertrichosis of the face in women. 
 
 Lotions (washes). — Vinegar may be utilized, or weak solutions of 
 hydrochloric acid (1 to 2 : 500), lemon juice, also watery or alcoholic 
 watery solutions of sublimate (1 to 2 : 500), etc. 
 
 For hairs of the face, reliance can be placed only on applications 
 of peroxide water repeated several times daily, or on the peroxide 
 cream a prescription for which follows: 
 
 LOTIONS FOR CHLOASMA. 
 
 Hydrarg. bichlorid 1.0 
 
 Alcohol q. s. 
 
 Plumbi acetat., 
 
 Zinci sulphat aa 2.0 
 
 Aq. distillata 250.0 
 
 (Hardy.) 
 Hydrarg. bichlorid., 
 
 Ammonii chlorid aa 0.1 
 
 Emulsion of almonds 100.0 
 
 (Brocq.) 
 In this formula, tinct. benzoin 5.0 may be substituted for the ammon. chlorid. 
 
 The applications must be made in the morning and again in the 
 evening; during the night, salves or ointments are applied. 
 
 Ointments. — Creams, pastes and salves which contain sufficiently 
 strong proportions of hydrogen peroxide, acetic acid, mercurial salts, 
 or sulphur and naphthol, possess a more or less strong bleaching 
 action. 
 
 PEROXIDE CREAM 
 
 Hydrogen peroxide water , . . . . 15.0 
 
 Vaselin 10.0 
 
 Lanolin 5.0 
 
 Oxide of zinc 1.0 
 
 Bichloride of mercury .., 0.5 
 
 F. hebra's SALVE. 
 Calomel, 
 
 Bismuth subnitr aa 6.0 
 
 Lard or vaselin 90.0 
 
 The most energetic treatment of pigmentations consists in the 
 employment of exfoliation by means of strong resorcin pastes or 
 mixtures [but they have only a temporary effect]. 
 
 Plasters. — Mercurial, carbojized mercurial and red plaster are 
 useful. 
 
734 APPENDIX 
 
 Whatever remedy has been employed, the treatment must be 
 interrupted for a few days as soon as the skin becomes reddened and 
 inflamed; the irritation should be soothed by means of a cream, or 
 a starch glycerite with an addition of bismuth carbonate and kaolin 
 (aa20 : 100). 
 
 7. REDUCING AGENTS. 
 
 Under this name we include a series of extremely valuable derma- 
 tological remedies which have the common feature of being more or 
 less avid of oxygen. This property, according to Unna, accounts for 
 their biological action. 
 
 Weak reducing agents, or even strong reducing agents employed 
 in weak dosage or for a short time, are keratoplastic, antiseptic, 
 relieve congestion and itching. Strong reducing agents are exfoli- 
 ating, highly irritative and give rise to severe epidermo-dermatitis. 
 
 Judging from my experience, in conformity with that of Jadassohn, 
 the progressive order of activity of the usual reducing agents is 
 apparently as follows: mercurial salts, resorcinol, sulphur and sul- 
 phur-containing remedies, tars (ichthyol, thiol, tumenol, coal-tar, 
 wood-tar, oil of birch, oil of cade); the most energetic are undoubt- 
 edly pyrogallol and chrysarobin. 
 
 The therapeutic investigation of a large series of derivates of 
 these substances, which have been extolled as less toxic and less 
 irritative, has been carried out only outside of France and not 
 always with the necessary thoroughness and disinterestedness. It 
 is useful to know the names of some of these: lenigallol or tripyrate 
 (tri-acetate of pyrogallol), eugallol or mono-pyrate (mono-acetate), 
 saligallol (disalicylate) ; gallanol, eurobine or trichrysate (triacetate 
 of chrysarobine), etc. 
 
 Reducing agents are employed under the most varied forms in 
 kerosis and its complications, in the dry psoriatiform and lichenoid 
 eczemas, in 2)soriasis, in the parakeratoses in general, in the lichens, 
 etc. 
 
 In the choice of excipients and combinations, the fact must be kept 
 in mind that the wood-tars (of pine, juniper; or cade oil, etc.), have 
 an acid reaction, whereas mineral or coal-tar is alkaline. 
 
 Watery Lotions. — Ichthyol (sulpho-ichthyolate of ammonium) and 
 thigenol are the only tars soluble in water. In order to render the 
 other tars miscible with water, they must be emulsified with the 
 assistance of saponine (saponined coal-tar) or in certain excipients 
 such as retinol (a product of dry distillation of colophane); the 
 opalol of Caillat and the collosol of Pepin are neutral soaps in which 
 various tars can be emulsified; their use is clean and very con- 
 venient. The tars are also incorporated into solid soaps (ichthyol 
 soap, tar soap, cade oil soap, etc.). 
 
REDUCING AGENTS 735 
 
 Sulphur is rarely employed dissolved; in carbon bisulphide, etc., 
 it is dangerous; a very active commercial solution comes in cedar oil, 
 known as denisol (7 per cent, of sulphur). The general preference 
 is to employ sulphur either in suspension or in the colloidal state 
 (denisoline), in lotions, either in the state of sulphides, or in soaps 
 (sulphur soaps, sulphur-naphthol soaps). 
 
 The following two prescriptions are of every-day use: 
 
 CAMPHORATED SULPHUR LOTION (KEROSIS, ACNE, ROSACEA, 
 ECZEMATIDES) . 
 
 Precipitated sulphur 10.0 
 
 Spts. of camphor 20.0 
 
 Glycerin 5.0 
 
 Rose water, 
 
 Water aa q. s. ad 100.0 
 
 SULPHUR LOTION (PITYRIASIS CAPITIS, SEBORRHEA) . 
 
 Potassium sulphuret 2 . to 4 . 
 
 Water 100.0 
 
 Or preferably: 
 
 Potass, sulphuret. liquid, 30 to 100 drops to a i glass of hot water. 
 
 [The following is a useful modification of the well-known 
 
 LOTIO ALBA (ACNE, KEROSIS, ETC.). 
 
 Solution sat. zinci sulphatis, 
 
 Solution sat. potassii sulphuretti aa 50 . 
 
 Spts. odorati , 10.0 
 
 To this mixture, beta naphthol 0.5, or resorcinol 2.0, or some- 
 times glycerin 10.0, may be added.] 
 
 Soluble mercurial salts may also serve in lotions: 
 
 ACID MERCURIAL LOTION (ACNE) . 
 
 Hydrarg. bichlorid 0.2 
 
 Ac. acetic 1.0 
 
 Tct. benzoin 5.0 
 
 Kaolin 5.0 
 
 Alcohol 20.0 
 
 Aquai 70.0 
 
 MERCURIAL LOTION FOR THE SCALP. 
 
 Hydrarg. bichlorid 0.2 
 
 Ammonii chlorid (or resorcinol or chloral hydrate) . . . . 1.0 
 
 Aq. lauro-cerasi ■. 10.0 
 
 Water • 90.0 
 
 Moist Dressings. — Under this form I have employed only resorcinol 
 (0.25 to 1 : 100) and especially ichthyol (2 to 10 : 100), with favor- 
 able results. 
 
736 APPENDIX 
 
 Baths. — There is no advantage in the employment of reducing 
 agents in the form of baths. However, sulphur baths (hepar 
 sulphuris 50.0 to 100.0) and the so-called Bareges baths enjoy a 
 classical reputation. 
 
 bareges' bath. 
 
 Sodium monosulphide 60.0 
 
 Sodium chloride (dry) 60.0 
 
 Sodium carbonate 30.0 
 
 For one bath. 
 
 TAR BATH (BALZER). 
 
 Oil of cade 50 to 100.0 
 
 Fl. extr. quillaya 10.0 
 
 Yolk of one egg, 
 
 Water 250.0 
 
 For one bath. 
 
 Alcoholic and Ethereal Lotions. — Washes of this kind are applicable 
 in the treatment of kerotic affections of the hairless skin (seborrhea, 
 acne) or more especially of analogous affections of the hairy scalp. 
 When the scalp is very dry, castor oil (1 to 5 : 100) may be added to 
 the alcoholic lotions. The prescriptions here given as examples 
 may be combined in a variety of ways with stimulating mixtures. 
 
 LOTIONS FOR THE SCALP (PITYRIASIS, KEROTIC ALOPECIA). 
 
 1. Beta-naphthol 0.10 
 
 Hydrarg. bichlorid . 20 
 
 Resorcinol, 
 
 Amnion, chloride, 
 
 ( 'liloral hydrat aa 0.5 
 
 Spts. lavandulse 100.0 
 
 2. Hydrarg. bichlor 0.10 
 
 Ac. salicyl 0.20 
 
 Liq. carbonis deterg. 
 
 Spts. sether., 
 
 Spts. rosmarini aa, 15.0 
 
 Spts. vini 55.0 
 
 3. 01. Rusci, 
 
 01. cadini aa 1.0 
 
 Tct. quillaya: 20.0 
 
 Alcohol (60 per cent.) 80.0 
 
 Ointments. — According to the degree and depth of action which it 
 is desired to obtain, use is made of creams, pastes or salves. 
 
 The creams are prepared with cold cream, cerate, vasolanoline, 
 or starch glycerite, incorporating calomel (2 to 10 : 100), turpeth 
 mineral, yellow oxide of jncrcury (2 to 5 : 100) or precipitated 
 sulphur (2 to 30 : 100). 
 
REDUCING AGENTS 737 
 
 In France, oil of cade is traditionally used in psoriasis in the form 
 of glycerite: 
 
 CADE OIL GLYCERITE. Mild . strong . 
 
 01. cadini 15.0 50.0 
 
 Saponis viridis or extr. quillaya (to emulsify) . . q. s. 5.0 
 
 Glycerite of starch neutral 85.0 45.0 
 
 01. caryophyl q. s. q. s. 
 
 A glycerite can be transformed into a paste by adding to it kaolin 
 and magnesium carbonate (aa 10 to 15 : 100) ; the glycerites have 
 the advantage of permitting easy cleansing of the skin. 
 
 Pastes are more active and more convenient to use; their con- 
 stituents may vary practically indefinitely. The following pre- 
 scriptions are commonly employed by me (figured or psoriasiform 
 eczematides, lichenoid eczemas, etc.) : 
 
 ICHTHYOL SULPHUR PASTE. 
 
 Sulphur precip 3.0 
 
 Ichthyol 5.0 
 
 Resorcinol 1.0 
 
 Zinci ox., 
 
 Starch aa 8.0 
 
 Petrolati, 
 
 Lanolin aa 10.0 
 
 TAR SULPHUR PASTE. eak . strong . 
 
 Sulphur, precip 3.0 5.0 
 
 01. cadini 5.0 10.0 
 
 Ac. salicyl 1.0 1.0 
 
 Resorcinol -. 1.0 1.0 
 
 Zinci ox., 
 
 Talci aa 20.0 18.0 
 
 Petrolati 50.0 47.0 
 
 The formulas of these pastes can be well-nigh indefinitely modified 
 by changing the nature of the powders or the fats; by replacing the 
 ichthyol and cade oil with birch oil or other tars, or with extracts 
 several satisfactory types of which are on the market (oleocade, 
 oxycade); by employing other forms of sulphur, or by introducing 
 mercurial salts. It should be remembered that except in the case 
 of cinnabar (red mercuric sulphide), the association of sulphur and 
 mercurials produces a black sulphide. 
 
 Salves are more particularly adapted to obstinate cases and to 
 the treatment of certain regions. 
 
 The reducing agent is customarily introduced in a dose of 5 : 100 
 and the mordant (salicylic acid, resorcinol) in a dose of 1 : 100, but 
 there are numerous exceptions. 
 
 For the scalp (kerosis, pityriasis, seborrhea, psoriasis), Sabouraud 
 considers sulphur and sulphur derivatives as especially adapted to 
 the oily forms and cade oil or its substitutes to the scaly condi- 
 47 
 
7: is APPENDIX 
 
 tions. \ irginia cellar oil lias been shown by him to be capable of 
 assisting or replacing cade oil, which bas a very unpleasant odor, 
 in lotions or ointments. 
 
 SALVES FOR THE SCALP AND BEARD. 
 
 1. Sulphur precip., 
 
 01. rusci aa 5.0 
 
 Resorcinol 1.0 
 
 Ongt. Sapon. (Section 5) 90.0 
 
 2. 01. cedri 
 
 01. cadini deodorisati aa 5.0 
 
 Hydrarg. ox. flav. 
 
 Resorcinol aa 1.0 
 
 Petrolati, 
 
 Lanolin aa 10.0 
 
 (Sabouraud.) 
 
 FOR THE FACE (PITYRIASIS, ECZEMATIDES) . 
 
 1. Calomel, vap. parat., 
 
 Tannin, alcoh. parat aa 3.0 
 
 Vaselin 100.0 
 
 2. Sulphur precipi, 
 Cinnabar, 
 
 Bals. Peruv aa 3.0 
 
 Vaselin 100.0 
 
 FOR THE BODY. COMPOUND SALVE (PSORIAM- . 
 Pyrogallol, 
 Ac. salicylic, 
 
 Resorcinol aa 1.0 
 
 Sulphur precip., 
 01. rusci, 
 
 Ol. cadini aa 2.0 
 
 Vaselin, 
 Lanolin, 
 Adipis aa 20 to 2.5.0 
 
 STRONG PYROGALLIC SALVE (OBSTINATE LICHENOID ECZEMA, 
 PSORIATIFORM ECZEMATIDEs) . 
 
 Pyrogalloli 6.0 
 
 Ac. salicyl 3.0 
 
 Picis liq., 
 
 Ichthyol aa 20.0 
 
 Cerati 50.0 
 
 The employment of pyrogallol salves must be very closely watched 
 on account of the poisoning threatened by this agent. I have found 
 that ehrysarobin salves of very weak concentration il : 4(10 to 
 1 : 300 in lard), which have been recommended on various sides 
 (Jadassohn, Sabouraud) are practicable when properly prepared 
 and cautiously employed in progressive doses (pityriasis rosea, 
 eczematides). 
 
REDUCING AGENTS 739 
 
 [dreuw's ointment (psoriasis, lichen simplex chronicus, 
 keratoid eczemas, etc.). 
 
 Ac. salicylic 10.0 
 
 01. rusci, 
 
 Chrysarobini aa 20.0 
 
 fPetrolati 20.0 
 
 ■j 01. theobromat . 5.0 
 
 [Saponis viridis 25.0 
 
 (Modified.) An unscientific but powerful and effective reducing agent. To be 
 used in courses of five days followed by a three- to five-day course of Lassar's paste.] 
 
 Certain mixtures, although containing active substances in fairly 
 strong dosage, are often admirably tolerated, even in acute attacks 
 of eczema. Caution in their use is nevertheless indicated; after 
 the cutaneous susceptibility of the patient has been tested by appli- 
 cations of brief duration, they may be employed in permanent 
 inunctions. 
 
 COMPOUND BALSAM (MODIFIED DTJRET'S BALSAM). 
 
 Resorcinol 2.0 
 
 Menthol, 
 
 Guaiacol • aa 5.0 
 
 01. cadini, 
 
 Sulphur ppti aa 15.0 
 
 Picisliq 18.0 
 
 Sodii boratis . .36.0 
 
 Camphor, 
 
 01. ricini aa 40 . 
 
 Glycerini . . .54.0 
 
 Aceton 80.0 
 
 Lanolin 100.0 
 
 laillier's salve (keratodermas). 
 
 Sulphur ppti., 
 
 01. cadini, 
 
 Picis liquid, 
 
 Saponis viridis . . . . aa 25 . 
 
 CHAULMOOGRA SALVE (PRURIGO) . 
 
 Chaulmoogra oil 5.0 
 
 Sulphur 8.0 
 
 Camphor 12.0 
 
 Tar 15.0 
 
 Vaselin 62 . 
 
 Modified Baissade balsam. 
 
 Paints and Varnishes. — It is sometimes advantageous to employ 
 reducing agents by applying them with a brush and covering with a 
 powder, a zinc paste or a varnish. This is a practical method of 
 employing chrysarobin; the latter is also very conveniently used 
 in the form of pomatum- or salve-sticks. 
 
740 APPENDIX 
 
 Pyrogallol 5 to 10.0 
 
 Ether sulph., 
 
 Spts. vini rect aa 45.0 
 
 Cover with a layer of zinc-paste. 
 
 Chrysarobin 10.0 
 
 Chloroform 90.0 
 
 ( 'over with traumaticin : 
 
 Gutta-percha 10.0 
 
 Chloroform 90.0 
 
 CHRYSAROBIN SALVE-STICKS. 
 
 Chrysarobin 10.0 
 
 Petrolati 30.0 
 
 Cerae 30.0 
 
 Butyr. cacao 20.0 
 
 Paraffini duri 10.0 
 
 Incorporate the chrysarobin with the vaselin, melt the other ingredients and mix. 
 Cool in cylindrical molds. 
 
 Solutions of various tars, coal-tar as well as vegetable tars, may 
 be prepared in alcohol-ether, or in benzol and acetone, applied with a 
 brush and covered with a zinc paste. They are sometimes incor- 
 porated with collodion. 
 
 TINCTURE OF TAR (SACK). 
 
 Coal tar 10.0 
 
 Benzol 20.0 
 
 Acetone 70.0 
 
 Use unfiltered. 
 
 OIL OF CADE COLLODION (LICHEN PLANUS). 
 
 Collodii flex 15.0 
 
 Alcohol absolut., 
 
 Ether aa 4.0 
 
 01. cadini 5.0 
 
 Ol. rusci 1.0 
 
 Dind (Lausanne) and Brocq have brought into vogue applica- 
 tions of crude coal-tar previously washed to free it from the excess 
 of alkali. 
 
 The coal-tar is spread over the skin by means of a brush, allowed 
 to dry, then dusted with talc powder; the application is touched up 
 every day or every other day and the coating is allowed to act during 
 four to eight days. Far from being as irritative as one might believe, 
 coal-tar is as a ride readily tolerated under this form, even in cases 
 of oozing eczema; in hospital practice, it advantageously replaces 
 the compound balsams which are far more expensive. Unfortu- 
 nately, coal-tar is not a definite product and its composition varies 
 enormously, according to its source. 
 
CICATRIZING AND KERATO PLASTIC AGENTS 741 
 
 Plasters. — In the form of plasters the reducing agents exert an 
 energetic action. The most common are mercurial, resorcinol, oil 
 of cade and tar plasters; it is noteworthy that pyrogallol and 
 chrysarobin plasters are not well tolerated. 
 
 8. CICATRIZING AND KERATOPLASTY AGENTS. 
 
 A medicinal agent produces neither cicatrization nor epidermisa- 
 tion; these are curative effects on the part of the organism. 
 
 The physician's part is limited to: (1) protecting the cutaneous 
 lesions against external irritants and against secondary infections; 
 (2) putting them in the best possible condition for the fight against 
 the microbes and for a proper repair; (3) accessorily, stimulating a 
 sluggish repair-process. 
 
 In this respect it is greatly to the interest of the dermatologist to 
 take into consideration the experience of operating surgeons and 
 proceed in conformity therewith. For a number of years there was 
 a tendency to replace antiseptic methods by the aseptic treatment 
 of simple wounds. In the course of the great war, it was soon recog- 
 nized in case of primarily or secondarily infected wounds that the 
 at first very popular painting with iodine as well as applications of 
 peroxide water, ether, permanganate, etc., were inadequate and even 
 injurious. 
 
 Surgical "toilet", as timely and complete as possible, followed 
 by progressive antisepsis, are favored at the present day. 
 
 In cutaneous pathology, conditions are different from those 
 obtaining in surgery. I shall endeavor to arrange the problems which 
 arise under a small number of headings. 
 
 Aseptic or Slightly Infected Lesions. — For admittedly clean surgical 
 wounds, aseptic dressings are sufficient. Traumatic wounds, which 
 are always infected or promptly liable to infection, burns, chemical 
 dermatitis, etc., should be treated by one of the following measures: 
 
 Moist dressings with weak antiseptic solutions, selecting the least 
 irritating; the so-called cytophylactic solutions (§1) are especially to 
 be recommended, such as that of Prof. Delbet (Acad, des Sciences 
 and Acad, de Med., Sept., 1915). 
 
 Very interesting in its principle, convenient and economical, is 
 the mechanically antiseptic fixogen dressing, devised by Mouchet 
 and Loudenot (Archiv. de Med et de Pharm. milit., Jan., 1917, p. 
 97). It consists of a varnish, at first known as fixol, analogous but 
 preferable to the various mastisols, aseptofix, etc.; it is employed by 
 painting it on the wound or the lesion and its surroundings, without 
 preliminary disinfection; it is not irritative, agglutinates microbes, 
 opposes their entrance and firmly fixes the layers of aseptic gauze 
 with which it is covered after a minute's drying. 
 
742 APPENDIX 
 
 The paraffinizaticm of wounds and burns by fusible mixtures 
 (ambrine) accomplishes a non-adherent isolation, which has the 
 fault, however, of being impermeable to secretions. I have previ- 
 ously stated that the dressing of burns and painful dermatitides 
 with fixed oils to which essential oils have been added (gomenol oil, 
 for example) or with compound oils known as pyroleol or phlyctol 
 which are analgesic and aseptic, is preferable in my opinion. 
 
 Infected Wounds and Ulcerations. — Progressive moist antiseptic 
 dressings, the borated sodium hypochlorite solution of Carrel- 
 Dakin (calcium chloride 200, sodium carbonate 100, sodium bicar- 
 bonate 50, boric acid for neutralizing; the solution to be prepared 
 extemporaneously) employed as a continuous local bath, has proved 
 to be extremely valuable for the sterilization of war-wounds and is 
 worthy of being likewise applied to the treatment of certain ulcers. 
 
 Dressings with the polyvalent serum of Leclainche and Vallee 
 (serum of horses which have been immunized against the germs of 
 the various suppurations), by favoring phagocytosis and regener- 
 ation of the anatomical constituents, accomplish both physiological 
 antisepsis and cytophylaxis (Presse Medicale, April 2, 1917, p. 187). 
 
 Progressive chemical disinfection can also be aimed at by the 
 employment of various powders. Vincent's powder (§2) seems to me 
 superior to iodoform and its analogues, to ectogen, etc. Calcium 
 chloride in the natural state, arsenobenzol as a powder, etc., are 
 customarily employed on ulcerations of mucous membranes; 
 methylene-blue still has its adherents. 
 
 Various antiseptic salves, the ingredients of which have been 
 given above (see Sections 2 and 3), notably Reclus' salve, are also 
 considered as assisting cicatrization. Colloid silver salve (10 : 100) 
 is entitled to special mention. 
 
 Rhagades chaps, cracks. — These are treated either by mild cauteri- 
 zations, or by painting them with steresol, adhesol, Commandeur's 
 balsam, or balsam of Peru. 
 
 Sluggish Cicatrizations. — Cauterizations with silver nitrate, 
 chromic acid, etc., will check exuberant granulations. Grafts are 
 indicated on extensive granulating surfaces and promise a more 
 flexible and less contracting cicatrix. 
 
 In case of sluggish ulcers, recourse may be had either to strong- 
 antiseptics, stimulants and mild caustics, or to styrax ointment 
 and its analogues, as well as balsam of Peru. Occlusion by diachy- 
 lon or medicated plasters, or by zinc-gelatin, is sometimes sufficient. 
 Heliotherapy, light-baths, hot-air douches, high frequency currents, 
 are sometimes of the greatest value. 
 
STIMULANTS AND RUBEFACIENTS 743 
 
 It must not be neglected to place the affected limb in a suitable 
 position and to order, according to the cases, either immobilization 
 or on the other hand, systematic gymnastic exercises. 
 
 9. STIMULANTS AND RUBEFACIENTS. 
 
 These are employed in the passive erythemas, in hyperidrosis of the 
 feet, in the alopecias, in lupus erythemafodes, etc. 
 
 They are represented by alcohol, alcoholic preparations and 
 tinctures, ether, chloroform, the volatile oils, camphor, mustard, 
 iodine and the acids, which supply the basis of the majority of 
 stimulating topical agents; the latter are almost invariably used 
 in the form of liniments: 
 
 Liniments. — for frost-bite, hyperidrosis, etc.: 
 
 1 . Tinct. iodin (or tannin) 1 to 5 . 
 
 Spts. camphor 100.0 
 
 2. Spts.'terebenth. 3.0 
 
 Spts. camphor 47.0 
 
 Spts. saponat 50.0 
 
 3. Aq. ammonia? fort 5.0 
 
 Spts. camphor 15.0 
 
 01. amygdal. dulc 80 . 
 
 4. Ac. tannici, 
 Resorcinol, 
 
 Ichthyol aa 2.0 
 
 Glycerini 10.0 
 
 FOR STATIONARY LUPUS ERYTHEMATODES AND ALOPECIA. 
 
 Phenolis, 
 
 Tinct. iodi, 
 
 Chloral hydrat aa 5.0 
 
 Paint on the surface. 
 
 FOR ALOPECIA AREATA . 
 
 Ac. acetic glacial 1-0 
 
 Chloral, hydrat 4.0 
 
 Etheris sulph ..30.0 
 
 Apply with gentle friction. 
 
 FOR DIFFUSE ALOPECIA. 
 
 1. Tinct. cantharidis 5.0 
 
 Tinct. jaborandi, 
 
 Spts. melissse aa 15.0 
 
 Spts. odorati 65.0 
 
 2. Aq. ammonia fort 2 to 5.0 
 
 Liq. picis alkalini, 
 
 Spts. camphor aa 15.0 
 
 Alcohol, 60 per cent 70.0 
 
 3 . Quininse muriat 10 
 
 Tinct. jaborandi 20.0 
 
 Spts. ajtheris 80.0 
 
 01. verbense Q- s - 
 
744 APPENDIX 
 
 The last mentioned stimulating lotions are applied on the scalp by 
 means of a small so-called "lotion-brush." The formulas can be 
 easily modified by incorporating into them, if indicated, one or 
 other of the reducing agents in use for the hairy regions. 
 
 10. ANTIPARASITICS. 
 
 Vegetable Parasites. — The destruction of the epidermophytes is 
 usually easy on the hairless skin (cf. pp. 519, 524, 520, 529, 531). 
 
 All the detergent remedies and strong antiseptics may be utilized, 
 such as soft soap, naphthol, phenol, mercurial salts in solutions or in 
 strong salves. The present preference is for iodine treatment with 
 the tincture (1 : 20 to 50) or in a vaseline salve (1 : 100) or for 
 chrysarobine in weak salves (1 : 300 to 1 : 3000). [For epidermo- 
 phytoses of the hands and feet, Whitfield's salve (ac. salicyl 1.0, 
 ac. benzoic 2.0, adipis benz. 12.0) is especially to be recommended.] 
 
 In case of tinea, chrysarobin salve-sticks may also be employed 
 (chrysarobin 10 to 30 gr., yellow wax 20 to 40, adeps lana? 50) or 
 according to the formula give above. 
 
 The employment of chrysarobin on the head, in strong salves, 
 or especially in plasters, requires great caution on account of the 
 highly irritative action of this remedy on the conjunctiva^. 
 
 After epilation (by .r-ray) it is advisable to rub the scalp with 
 dilute tincture of iodine, or with carbolized glycerine (1 : 50). 
 
 Animal Parasites. — Pediculosis. — According to the conditions 
 of the environment and other factors a choice should be made 
 between the following remedies: 
 
 Powders. — Naphthaline mixed with talc (50 : 100) ; N. C. I. mixture 
 of the British Army (naphthalene 96, creosote 2, iodoform2). 
 
 Liquids for Washes, Sprays or Sachets. — Benzine, xylol, petroleum, 
 turpentine oil (15 : 1000), camphorated oil (10 : 100), spirits of 
 camphor, carbolized water (2 : 100), chloroform water; vinegar 
 with sublimate (1 :500); parasiticide wash of the Hopital Saint- 
 Louis (sublimate 1, spirits of turpentine 130, glycerine 170, cam- 
 phorated alcohol 700); cresyl solutions (for example: paracresylol 
 or sapocresol 30, almond soap 15, water 1000, Choay). 
 
 Recently, various products derived from cresol have been recom- 
 mended, as well as various volatile oils, for example: 
 
 SOLUTION FOR SPRAYS. 
 
 Anisol (methyl-phenol) 0.03 to 0.05 
 
 Denatured alcohol, 
 
 Water aa 50.0 
 
 Kills lire in eight to ten minutes; to be employed several days in succession. 
 
antiparasitics 745 
 
 PARASITICIDE MIXTURE (LEGROUX) . 
 01. citronellae, 
 01. menthse pip., 
 
 01. eucalypti glob aa 300.0 
 
 Naphtalin pulv 100.0 
 
 To be used in "sachets," or in dilute alcoholic solution (5 to 100) as a wash. 
 
 Disinfection of clothing and bedding in the steam-sterilizer is of 
 great importance; shaving of the head and body hairs, when prac- 
 ticable, as well as ironing the clothes with a hot iron, are to be 
 recommended. 
 
 Salves. — These may be prepared from a large number of the above- 
 mentioned remedies. I repeat that I have found yellow mercury 
 salve most efficient and harmless in the treatment of phthiriasis 
 inguinalis (yellow oxide of the Hg. 10, oxide of zinc, 10, salicylic 
 acid and resorcin aa 1, vaseline 78.) 
 
 Scabies. — There is an abundance of formulas; the majority are 
 based on sulphur. 
 
 Balsam of Peru and styrax ointment are also excellent against 
 the itch and may be employed pure or incorporated in vaseline, or 
 dissolved in alcohol with an addition of castor oil. 
 
 HOPITAL SAINT LOUIS FORMULA. 
 
 Sulphur, sublimat 20.0 
 
 Potass, carbonat 8.0 
 
 Aq. destil 8.0 
 
 Adipis 64.0 
 
 HELMERICH-HARDY SALVE. 
 
 Sulphuris nor 20.0 
 
 Potass, carbonat 10.0 
 
 120.0 
 
 VLEMINCKX' SOLUTION. 
 
 Sublimed sulphur 250.0 
 
 Quicklime . . . 150.0 
 
 Water 2500.0 
 
 Boil down to 1500. 
 
 WILKINSON-HEBRA SALVE. 
 01. Rusci, 
 
 Sulphur, sublimat aa 10.0 
 
 Saponis viridis, 
 
 Adipis aa 20.0 
 
 Cretse pulv 5.0 
 
 BOURGUIGNON'S SALVE. 
 
 01. lavandulse, cinnamonii, 
 
 Menthse pip., caryophyl '. . . . aa 2.0 
 
 Tragacanth 4.0 
 
 Potass, carbonat .30.0 
 
 Flor. sulphur 90.0 
 
 Glycerini 180.0 
 
746 APPENDIX 
 
 PERU BALSAM SALVE. 
 
 Bals. Peruv 15.0 
 
 Styracis liq 20.0 
 
 Cretse prsep 20.0 
 
 Adipis (or petrolati) 45.0 
 
 With the two last named salves, disinfection of the clothing is 
 
 said to be not absolutely necessary but the bedding must be dis- 
 infected. 
 
 [Sherwell's method is simple and effective: The patient, stripped 
 and in bed, rubs himself vigorously every night with the dry powder 
 of flowers of sulphur (sulphur sublimatum), leaving the spilled 
 powder between the sheets and under the night-clothes. The cure 
 requires about a week. It has the merit, of simplicity and great 
 economy, especially where an entire family has to be disinfected. 1 
 
 11. CAUSTICS. 
 
 The employment of caustics for the destruction of small tumors, 
 proliferations and nevi, is becoming more and more restricted; the 
 preference is accorded to the galvano-cautery, superheated air and 
 carbonic acid snow, the action of which is instantaneous and more 
 easily graduated. 
 
 Use is still sometimes made, however, of the following: nitric, 
 hydrochloric, lactic, trichloracetic, chromic, arsenious acids; caustic 
 potash; zinc chloride, corrosive sublimate, acid nitrate of mercury, 
 pure phenol, resorcin, pyrogallol, permanganate of potash, etc. 
 Ordinary formalin has been recommended for the destruction of 
 proliferations. 
 
 Arsenious acid is the remedy of choice for epitheliomas, in suspen- 
 sion in a liquid rather than in the form of a paste. 
 
 CZERNY-TRUNECEK SOLUTION. 
 
 Arsenic triox 1-0 
 
 AquEe, 
 
 Alcohol (90 per cent.) aa 50.0 
 
 Shake. For method of use see p. 688. 
 
 ARSENICAL POWDER. 
 
 Arsenic triox 1.0 
 
 Carbonis ligni pulv 2.0 
 
 Hydrarg. sulph. rubri 5.0 
 
 Mix with a little mucilage. 
 
 canquoin's paste (carbuncle). 
 
 Zinci chloridi 8.0 
 
 Zinci oxidi 2.0 
 
 Amyli tritici 6.0 
 
 A«i. dest 1.0 
 
 Make a paste. 
 
DIET 747 
 
 VIENNA PASTE. 
 
 Potassii hydrox 5.0 
 
 Calcis ustse . 6.0 
 
 Before use, make a paste by moistening with alcohol. 
 
 Silver nitrate has only a very superficial action. It is often em- 
 ployed in pencils or in watery or alcoholic solutions (1 : 10 to 30) 
 on mucous patches, erosions and for the control of exuberant granu- 
 lation of wounds. 
 
 Its action can be considerably strengthened by the so-called 
 "two pencil" procedure: the surface which has been cauterized with 
 silver nitrate is passed over with a pointed pencil of metallic zinc. 
 This procedure is serviceable for example in cases of ulcerated lupus. 
 
 I have often advantageously utilized the following caustic pastes, 
 advocated by Unna : 
 
 GREEN PASTE (LUPUS VULGARIS). 
 
 Antimonii trichlorid. 
 
 Ac. salicylic aa 2.0 
 
 Creosoti (Beechwood), 
 
 Ext. cannabis Ind aa 4.0 
 
 Lanolin 8.0 
 
 WHITE CAUSTIC PASTE (TUBERCULOSIS VERRUCOSA). 
 
 Caustic potash, 
 
 Quicklime, 
 
 Green soap, 
 
 Distilled water aa 5.0 
 
 Apply over the lupus or verrucous patch, by means of a spatula, 
 a layer of paste about the thickness of a knife-blade; wipe off the 
 edges with cotton; cover with a large piece of zinc oxide plaster. 
 In case of the white paste, it is advisable to interpolate a wad of 
 moist cotton between the caustic and the plaster. The pain is 
 never excessive and does not last long. At the end of a few hours 
 the plaster is removed and moist dressings are applied. In case of the 
 green paste, the applications are repeated twice a week on an aver- 
 age, until total destruction of the diseased tissue has been accom- 
 plished. 
 
 I have found these preparations preferable to cauterizations with 
 pyrogallol, resorcin in strong salves, or potassium permanganate 
 in concentrated solution or as a powder, which are employed by 
 others. 
 
 12. DIET. 
 
 It would be altogether erroneous to assume that there is an 
 alimentary regimen applicable to all cutaneous diseases. Nor is it 
 a given eruption which governs the diet, but rather the general 
 
748 APPENDIX 
 
 nutritional disturbance of which it may be a direct expression or an 
 indirect consequence or which may create a predisposition to that 
 particular eruption. 
 
 In a patient suffering from a skin disease, the demonstration of 
 diabetes, anemia, "lymphatic" constitution, gastro-intestinal dys- 
 pepsia or enteritis, hepatic or renal insufficiency, nervousness, or 
 an intoxication or chronic auto-intoxication, etc., necessitates in 
 itself the appropriate diet, such as laid down in text-books of general 
 medicine. 
 
 Another point which must be thoroughly considered is the exist- 
 ence of infinitely variable, practically unlimited and often entirely 
 unexpected individual sensibilities and idiosyncrasies of intolerance 
 toward many articles of food and drink. It is therefore advisable 
 to make it a rule never to ignore the statements of patients in 
 regard to their intolerance of a given alimentary substance; on the 
 contrary, care should be taken to guide their observations in this 
 direction, while realizing that persons capable of trustworthy self- 
 observation are in a great minority, as pointed out by Jadassohn. 
 
 All dermatologists have encountered patients who attribute their 
 attacks of erythema, urticaria, pruritus or eczema, to the ingestion 
 of strawberries, mussels, game, pork, or champagne; others hold 
 milk, eggs, spinach, veal, etc., responsible. Although the available 
 information on the subject of anaphylaxes is of a kind to furnish the 
 explanation for a certain number of cases, the physician is justified 
 in remaining unconvinced until a positive demonstration has been 
 made. 
 
 At an}' rate, it would be unreasonable and exaggerated to forbid 
 to all patients what may have harmed a few; this would result in 
 the prescribing of an over-rigid and more or less impracticable 
 diet. 
 
 The physician may sometimes find it necessary to recommend 
 for a time an exclusive regimen such as an absolute milk diet, or 
 a purely carbohydrate regimen, permitting only successively the 
 addition of various kinds of foods and drinks; through this pro- 
 cedure, which is logical and to be recommended, one may hope to 
 trace the idiosyncrasy of the patient. It is always advisable in such 
 cases to be on one's guard against unintentional departures from the 
 regimen and against fraud. 
 
 [Some knowledge of cookery is a very useful acquisition on the 
 part of the physician. In excluding milk and eggs, for instance, it 
 must be remembered that these articles enter into many prepara- 
 tions of food, various sauces, most pastries, etc.] 
 
 After these general statements, I am adding a list of the beverages 
 and foods which are often found to be injurious to patients suffer- 
 ing from hyperemic or pruritic dermatoses {erythemas, urticarias, 
 
DIET 749 
 
 eczemas, neurodermatitis, lichen planus, etc.), and which it is 
 customary to prohibit more or less strictly. 
 
 Alcoholic beverages in general (especially unmixed wine, cham- 
 pagne, liqueurs, bitters, medicated wines, strong beers, cider), as 
 well as coffee, tea and chocolate. 
 
 High meats and conserves (game, smoked meats, salted meats, 
 sausages, meat-pies, ragouts, galantines, foie gras) ; certain meats, 
 such as pork, duck, veal. 
 
 Deep-sea fish, smoked or salted fish, crabs, lobsters and shellfish. 
 
 Vegetables: Sorrel, spinach, tomatoes, stringbeans, asparagus, 
 cabbage, cauliflower, "sour krout," cucumbers, mushrooms, 
 truffles, raw salads. 
 
 Fruits: Strawberries, raspberries, gooseberries, melons, nuts 
 and figs. 
 
 All cheeses, except fresh non-fermented and salted cheese. Sweet- 
 meats and pastries. 
 
 In a general way, all condiments, vinegar, spices, mayonnaise 
 dressings, tartare sauces, mustard, etc. 
 
 This list will be seen to comprise among others: (1) Substances 
 possessing stimulating or irritative properties (alcohol, tea, coffee, 
 spices) ; fermented, changed substances or those suspected of being 
 so on account of their liability to change and containing toxins (high 
 meats and venison, meat-conserves, deep-sea fish) ; foods of difficult 
 digestion (salads, raw substances). 
 
 It goes without saying that restrictions or prohibitions must be 
 rendered with tactfulness and discrimination, adapting them not 
 only to the pathological conditions of the case but up to a certain 
 degree to the social standing of the patient. The diet must be 
 individualized, like all therapeutic prescriptions. Suggestions in 
 this respect may be drawn from the few general directions which I 
 have summarized in discussing the treatment of eczema. 
 
 [The divergence among competent dermatologists on so appar- 
 ently simple a question as the value of a non-nitrogenous diet in 
 psoriasis and some other dermatoses is certainly remarkable and 
 suggestive. In regard to urticaria, oedema circumscriptum and 
 similar affections which seem to be typical of an anaphylactic dis- 
 turbance, how often does the most rigid inquest fail to disclose the 
 peccant alimentary or autotoxic substance! The recently introduced 
 "cutaneous tests" that in theory seemed so promising have proved 
 disappointing in practice.] 
 
 In conclusion, I consider it necessary to emphasize once again the 
 importance, which I regard as very great, of ascertaining the con- 
 dition of the teeth (notably in erythrosis, in many eczemas and 
 pruriginous dermatoses, in alopecia, etc. Dental caries, or the loss 
 of a large number of teeth, an abundance of tartar, pyorrhea alveo- 
 
750 .1 PPENDIX 
 
 laris, inflammations of the gums or gingivitis are certainly the start- 
 ing-point not only of reflex disturbances but also of a real chronic 
 intoxication. The latter is the effect either of the constant swallow- 
 ing of putrid products and pus, at all hours of the day and night; or 
 of the arrival in the stomach of imperfectly masticated and poorly 
 insalivated food; the latter, not being in a condition to undergo in 
 a proper way the action of the digestive juices, will permit and favor 
 abnormal gastro-intestinal fermentations. 
 
 After having experienced it on repeated occasions, I am now 
 convinced that putting the teeth in good condition, wearing a 
 suitable artificial denture, with proper care of the mouth, can 
 powerfully contribute to the inhibition of eruptive attacks, to the 
 improvement of the general condition of many patients; while 
 permitting the cure of skin diseases which had before resisted even 
 correct topical applications as well as the prescription of a Draconian 
 alimentary regimen. 
 
INDEX 
 
 Abscess, miliary, of little children, 
 Abscesses of axilla, tuberous, 544 
 Acant holysis, 174 
 Acanthosis, 64 
 
 nigricans, 242 
 Acarophobia, 482 
 Achromia, 320 
 Achromic nevi, 320 
 Acne, bromide, 476 
 
 cachecticorum, 385, 567 
 
 cornea, 385 
 
 decalvans, 385, 394 
 
 frontalis, 391 
 
 hypertrophica, 374, 385 
 
 iodide, 475 
 
 juvenilis, 385 
 
 keloid, 391 
 
 lupoid, 394 
 
 medicinal, 390 
 
 miliaris, 385 
 
 necrotica, 391 
 
 occupational, 390 
 
 papularis, 386 
 
 phlegmonous, 386 
 
 pilaris, 391 
 
 polymorphous, 386 
 
 punctata, 386 
 
 pustular, superficial, 386 
 
 rodens, 391 
 
 rosacea, 36, 385 
 
 rosea, 36 
 
 sebacea, 383, 385 
 
 syphilitica, 385 
 
 telangiectodes, 566 
 
 treatment of, 388 
 
 tuberosa, 386 
 
 variohformis, 385, 391 
 
 vulgaris, 385 
 Acne, cornee. 403 
 
 "sebacce," 209 
 Acneiform eczema, 90 
 
 lupus, 570 
 
 peripilar syphilid es, 396 
 
 syphilides, 398 
 
 tuberculides, 564 
 Acnes. 384 
 Acnitis, 398, 567 
 Acro-asphyxia, 36 
 
 446 
 
 Acrodermatitis atrophicans chronica , 
 344 
 
 continuous, 186, 216 
 Acrokeratoma, 212 
 Actinomyces, 599 
 Actinomycosis, 270, 599 
 Acute circumscribed edema, 49 
 Addisonian melanodermas, 325 
 Adeno-lymphocele, 364 
 Adenoma sebaceum, 672 
 Adenomata, 672 
 Adenomatous nevi, 672 
 Albinism, 320 
 Alcoholic solutions, 714 
 Aleppo boil, 648 
 Alimentary eruptions, 479 
 Allergy, 548 
 Alopecia atrophicans, 393 
 
 parrimaculata, 393 
 
 pseudo-favic, 394 
 Alopecias, 407 
 
 achromatous, 413 
 
 areata, 413 
 
 cicatricial, 412 
 
 circumscribed, 412 
 
 coronarius, 413 
 
 decalvans, 413, 414 
 
 diffuse, 408 
 
 of general disease, 411 
 
 kerotic, 408 
 
 non-cicatricial, 412 
 
 pathological, 408 
 
 pellicular, 409 
 
 pityroid, 409 
 
 premature, 409 
 
 regional, 408 
 
 seborrheic, 409 
 
 senile, 409 
 
 syphilitic, 411 
 
 totalis, 413 
 
 traumatic, 408 
 
 treatment of, 415 
 
 with fragile hairs, 413 
 Alopecic favus, 421 
 Anal pruritus, 488 
 Anaphylaxis, 460 
 Anatomical tubercle, 552 
 Anesthetics, local, 729 
 Anetoderma erythematosum of Jadas- 
 sohn, 345 
 
752 
 
 INDEX 
 
 Angina, herpetic, 152 
 
 Vincent's, 306 
 Angiohematic typhus, 57 
 Angiokeratoma, ol>4. tilt.") 
 Angiokeratotic tuberculides, 5(34 
 Angioma, 693 
 
 flat, 693 
 
 progressive multiple, 694 
 
 senile, 695 
 
 stellate, 695 
 
 tuberous, 693 
 Angiomatous Lupus, 554 
 Angiosarcoma, 707 
 Anidrosis, 442 
 Annamite ulcers, 301 
 Annular syphilide, 144 
 Anonychia, 431 
 Anthrax, 593 
 Anti-anaphylaxis, 461 
 Antiparasitics, 743 
 
 for animal parasites, 744 
 
 for pediculosis, 744 
 
 for scabies, 745 
 
 for vegetable parasites, 743 
 Antiphlogistics, 718 
 Antipruritic agents, 727 
 Antipyrin bulla?, 177 
 Antipyrinides, 473 
 Antiseptics and astringents, 722 
 
 strong, 726 
 Aphtha?, 306 
 Aplasia laminaris, 354 
 
 moniliformis, 418 
 Arciform syphilide, 144 
 Argas, 514 
 Argyria, 332 
 Arsenical dyschromias, 328 
 
 keratosis, 213 
 
 treatment of, 661 
 "Arthritide bulleuse," 179 
 Arthritism, 479 
 Arthropathic psoriasis, 105 
 Artificial dermatitides, 447, 467 
 
 eczema, 79 
 
 pigmentations, 321 
 
 pruritus, 482 
 Aspergillus, 599 
 
 lapidophyton, 528 
 Atrophic dermatoses, 335 
 
 lichen planus, 137 
 Atrophies, cicatricial, 339 
 
 cutaneous, 334 
 
 idiopathic, 343 
 
 linear, 341 
 
 macular, 341, 345 
 
 postsyphilitic, 342 
 
 regional, 353 
 
 reticular, 344 
 
 round, 342 
 
 sclerotic, in spots, 346 
 Atrophoderma, 334 
 
 pigmentosum, 355 
 
 Autotoxic eruptions, 479 
 
 erythemia, 28 
 
 urticaria, 46 
 Axilla, abscess of, tuberous, 544 
 
 B 
 
 Bai.axoposthitis, circinate erosive, 311 
 Balsamic erythemas, 473 
 Barlow's disease, 55 
 Baso-cellular epithelioma, 679 
 Bazin, acne pilaris of, 391 
 
 erythema induratum of, 274 
 
 pathogenic erythema of, 27 
 Bazin's hydroa, 176 
 Beard, eczema of, 74 
 Beauty spots, 664 
 Bed-bugs, 506 
 Biett, collarette of, 626 
 Biopsic pruritus, 487 
 Birthmarks, 664 
 Biskra boil, 648 
 
 button, 250 
 Black tongue, 229 
 Blastomycoses, 603 
 
 Busse-Buschke type of, 603 
 
 Gilchrist type of, 603 
 Blastomycosis, 270 
 Bleaching agents, 733 
 Blisters, 175 
 
 Blood, diseases of, dyschromias in, 328 
 Bockhardt, impetigo of, 167 
 Body-lice, 504 
 
 Boeck, acne necrotica of, 391 
 Boils, 540 
 
 Botryomycoma, 704 
 Boubas, 650 
 
 Bowen, precancerous dermatosis of, 236 
 Brocq, lupoid sycosis of, 394 
 
 pseudo-pelade of, 393 
 Bromide acne, 476 
 Bromidrosis, 443 
 Bromoderma tuberosum, 476 
 Bubo, syphilitic, 612 
 Buccal cavity, neoplasms of, ulcerative, 
 309 
 
 diphtheria, 305 
 
 gangrene, 308 
 
 herpes, 304 
 
 hydroa, 304 
 
 ichthyosis, 219 
 
 mucosa, erosions of, diphtheroid, 
 304 
 ulcerations of, 304 
 
 pemphigus, 304 
 
 pruritus, 488 
 
 psoriasis, 219 
 
 zona, 304 
 Bulla?, 174 
 
 acant holy tic, 174 
 
 antipyrine, 177 
 
INDEX 
 
 753 
 
 Bulla?, deep, 174 
 
 purulent, 174 
 
 subcorneal, 174 
 
 subepithelial, 174 
 
 superficial, l74 
 
 traumatic, 175 
 Bullous dermatoses, 174 
 accidentally, 175 
 
 erythema, 24 
 
 impetigos, 178 
 
 polymorphous erythema, 175 
 
 syphilides, 177, 620 
 
 toxicodermas, 177 
 
 urticaria, 45, 175 
 Burns, 450 
 
 of first degree, 451 
 
 of second degree, 451 
 
 of third degree, 451 
 Buttock, herpes of, 153 
 
 Cachetic ecthyma, 170 
 
 purpura, 54 
 Cachexias, dyschromias in, 328 
 Cacotrophia folliculorum, 402 
 Calcareous tumors, 692 
 Calcified epithelioma, 679 
 Callositas, 449 
 Callus, 449 
 Calvities, 408 
 
 hippocratica, 409 
 Calymmato-bacterium granulomatis, 
 
 251 
 Canaliculitis, 310 
 Cancer, green, 653 
 Cancers, epithelial, 676 
 Cancroid epithelioma, 677 
 Cancroids, 676 
 Canities, 416 
 Carafes, 528 
 Carbolic gangrene, 314 
 Carbunculus, 543 
 Carcinoma, secondary, 683 
 Carrion's disease, 593 
 Caustics, 746 
 Cellular nevi, 666 
 Cervical zona, 156 
 Chalazoderma, 372 
 Chancre, dwarf, 615 
 
 ecthymatous, 615 
 
 extragenital, 616 
 
 genital, 616 
 
 giant, 615 
 
 hard, 613 
 
 hypertrophic, 615 
 
 incipient, 597 . 
 
 mature, 597 
 
 miliary, 597 
 
 mixed, 283 
 
 papular, 597, 615 
 4S 
 
 Chancre redux, 615 
 
 simple, 596 
 
 soft, 281, 596 
 
 extragenital, 282 
 
 of genital mucosa, 316 
 
 syphilitic, 613 
 
 of genital mucosa, 311 
 of mouth, 307 ■ 
 
 ulcerative, 615 
 syphilitic, 283 
 Chancroid, 281, 596 
 Chancroidal folliculitis, 597 
 
 phagedena, 295 
 Cheiropompholyx, 85 
 Chilblains, 34 
 Chloasma, 324 
 Chloroma, 653 
 Chlorotic pemphigus, 192 
 Chromatorrhexis, 591 
 Chromidroses, 444 
 | Cicatrices, 336 
 Cicatricial alopecias, 412 
 
 atrophies, 339 
 
 depilating folliculitides, 392 
 
 epithelioma, flat, 681 
 
 folliculitis of hairless parts, 566 
 Cicatrizing and keratoplastic agents, 
 
 740 
 Circinate erosive balanoposthitis, 311 
 Circumscribed alopecias, 412 
 
 keratoses, 206 
 Clavus, 449 
 
 Cleansing and keratolytic agents, 730 
 Cohnistreptothrix, 599 
 Collarette, of Biett, 626 
 Colloid milium, 359, 692 
 Colored sweats, 444 
 Comedo, 385 
 
 Condyloma acuminatum, 238 
 Congenital elephantiasis, 361, 370 
 
 erythrodermas, 122 
 
 hyperkeratosis, 203 
 diffuse, 124 
 
 ichthyosis, 124 
 
 macroglossia, 370 
 
 malformations of nails, 431 
 
 malignant keratoma, diffuse, 124 
 
 pemphigus, 191 
 
 syphilis, 624 
 
 precocious, 625 
 
 xanthoma, 699 
 Conjunctiva, herpes of, 153 
 Connective-tissue tumors, 689 
 Contusiform dermatitis, 265 
 "Copper-nose," 374 
 Corns, 449 
 
 Cornu cutaneum, 677 
 Corona veneris, 144 
 Couperose, 36 
 Crab-louse, 505 
 "Crasse des vieillards," 209 
 Creams, 717 
 
INDEX 
 
 < Iretinism, 372 
 
 ( rvptococcus, 599 
 
 ( '\itis hvperelastica, 372 
 
 laxa, 372 
 ( !ylindroma, 682 
 ( 'vstic follicular adenomatous nevi, 071 
 
 sudoriparous adenomata, 672 
 ( Systicercus cellulosse, 515 
 Cysts, 670 
 
 dermoid, 671 
 
 epidermic, 670 
 
 traumatic, 671 
 
 follicular, 671 
 
 sebaceous, 670 
 
 scnms, 672 
 
 Darier's disease, 231 
 
 Date-boil, 648 
 
 Degeneration, senile, 357 
 
 Delhi boil, 648 
 
 Demodex folliculorum, 513 
 
 Depapillated plaques of tongue, 304 
 
 Dermatitides, artificial, 447, 467 
 
 due to mechanical causes, 448 
 physical causes, 450 
 
 induced, 467 
 
 occupational, 467 
 
 simulated, 471 
 
 traumatic eczematiform, SO 
 Dermatitis, acute benign exfoliating, 
 116 
 
 artefaeta, 183 
 
 atrophicans, 343 
 
 contusiform, 265 
 
 exfoliating, 117 
 
 of nurslings, 123 
 
 gangrenous, of children, 317 
 
 generalized exfoliative, 117, US 
 
 herpetiformis, 17(1 
 
 papillaris capillitii, 391 
 
 polymorphous, 179 
 
 sycosiformis atrophicans, 394 
 
 vacciniform, infantile, 168 
 
 venenata, 470 
 I termatolyses, 372 
 1 )ermatomycoses, 599 
 
 ulcerations of, 293 
 Dermatophobia, 482 
 Dermatophytes, 502 
 Dermatoscleroses, 334, 353. 
 I >ermatoses, atrophic, 335 
 
 bulbous, 174 
 
 accidentally, 175 
 
 caused by acari (mites), 507 
 by insects, 502 
 by worms and larva?, 514 
 
 dyschromic, 323 
 
 eruptive, 17 
 
 erythematous-squamous, 89 
 
 erythrodermic, 120 
 
 Dermatoses, hypertrophic, 361 
 
 infectious, 535 
 
 liacillary, 546 
 
 chronic, pustules of, 172 
 
 due to protozoa, 610 
 
 of leukemias, 651 
 
 nodular, 263 
 acute, 265 
 
 non-eruptive, IS 
 
 nosology of, 447 
 
 onychoses of, 434 
 
 papillomatous, 238 
 
 papular, 127 
 
 parasitic, 502 
 
 pigmentary, of legs, 323 
 
 precancerous, of Bowen, 236 
 
 proliferating, accidentally, 244 
 
 pustular, 161 
 
 sclerotic, 335 
 
 tropical proliferating, 249 
 
 tuberculo-ulcerative, 253 
 
 ulcerative', 2S1 
 
 vesicular, 149 
 Dermic gummas, 267 
 
 papules, 128 
 
 pustules, 160 
 Dermographism, 49 
 Dermoid cysts, (571 
 Desquamation of newborn, lamellar, 
 
 122 
 Desquamative erythema, 24 
 
 erythroderma of nurslings, 124 
 Diabetic eruptions, 480 
 
 gangrene, 316 
 
 xanthoma, 699 
 Diabetides, genital, 480 
 Diathetic pruritus, 484 
 Diet, 747 
 Diffuse congenital hyperkeratosis, 124 
 
 malignant keratoma, 124 
 Diphtheria, buccal, 305 
 
 cutaneous, 594 
 Diphtheroid erosions of buccal mucosa, 
 304 
 
 pemphigus, 187 
 
 stomatitis, 305 
 Discomyces minutissimus, 533 
 Disseminated miliary lupoid, 259 
 
 pigmentary spots, 325 
 1 >racunculus, ."ill 
 Dry eczema, 63, 72 
 
 erosions of tongue, 304 
 Duhring's disease, 17!) 
 
 rare dermatoses related to, 184 
 Dwarf chancre, 615 
 Dyschromias, 320 
 
 arsenical, 32S 
 artificial, 321 
 
 associated, 323 
 in cachexias, 328 
 diffuse, 325 
 
INDEX 
 
 755 
 
 Dyschromias in diseases of blood, 328 
 
 of leprosy, 327 
 
 of nervous diseases, 327 
 
 secondary, 321 
 Dyschromic dermatoses, 323 
 Dyscratic pruritus, 484, 487 
 Dysidrosis, 85 
 Dysidrotic eczema, 86 
 Dyskeratoses, 194, 230 
 
 follicularis, 231 
 
 lenticularis et discoides, 236 
 Dystrophic onychoses, 437 
 
 trichoses, 416 
 Dystrophies, cutaneous, 355 
 Dystrophy, papillary, 242 
 
 pigmentary, 242 
 le, 358 
 
 E 
 
 Ecchymoses, 52 
 Ecthyma, 169, 284 
 
 cachetic, 170 
 
 gangrenous, 317 
 
 scrofulous, 170 
 
 syphilitic, 170 
 
 terebrans, 171 
 
 scrofulosorum, 568 
 Ecthymatous chancre, 615 
 Eczema, 60 
 Eczema, acneiform, 90 
 
 acute disseminated, 87 
 
 artificial, 79 
 
 of beard, 74 
 
 between toes, 75 
 
 corneal, 214 
 
 dry, 63, 72 
 
 dysidrotic, 86 
 
 erysipeloid, 71 
 
 exudative, 71 
 
 of face, 75 
 
 fissured, 71 
 
 flanellaire, 92 
 
 folliculorum, 396, 564 
 
 of forearms, 75 
 
 generalized, 120 
 
 of hairy regions, 74 
 
 of hands, 75 
 
 hyperkeratotic, 64 
 
 impetiginous, 64, 71, 72 
 
 infantile, 65, 80 
 
 infected, 64 
 
 intertrigo, of infants, 75 
 
 keratotic, 72, 214 
 
 lamellar, 64 
 
 of legs, 75 
 
 lichenified, 71, 72 
 
 lichenoid, 64 
 
 marginatum, 74, 90 
 of Hebra, 524 
 
 microbic, 66 
 
 Eczema of nails, 435 
 
 of nipple, 75 
 
 nummular, 72 
 
 occupational, 65 
 
 orbicular, 75 
 
 orificial, 75 
 
 papulo-vesicular, 72 
 
 parasitic, 65 
 
 paratraumatic, 66, 73 
 
 pilaris, 379 
 
 psoriasis, 104 
 
 psoriatiform, 64 
 
 rubrum, 64, 71 
 
 of scalp, 74 
 
 scrofulosorum, 147 
 
 seborrheal, 63 
 
 seborrhceicum, 90 
 
 secondary, 87 
 
 senile, 65 
 
 solare, 65 
 
 squamous, 64, 72 
 
 traumatic, from scratching, 65 
 
 treatment of, 77 
 
 true, 83 
 
 tylotic, 72 
 
 varicose, 73 
 
 vesicular, 71 
 
 vulgare, 72 
 
 of war wounds, 66, 73 
 
 weeping, 63 
 
 of wrists, 75 
 Eczematides, 90 
 
 erythrodermic, 95 
 
 figured, 92 
 
 follicular, 395 
 
 peripilar, 95 
 
 pityriasiform, 93 
 
 psoriatiform, 95 
 Eczematization, 60 
 ! Eczematoid tuberculides, 564 
 Eczematosis, 60, 83 * 
 Edema, acute circumscribed, 49 
 
 malignant, 594 
 Edematous scleroderma, 347 
 Elastoma, 359 
 Elastorrhexis, 359 
 Electric erythema, 32 
 Elephantiasis, 361 
 
 arabum, 361 
 
 congenital, 361, 370 
 
 filarial, 361, 369, 515 
 
 grsecorum, 361, 578 
 
 nostras, 361, 367 
 
 papillomatous, 246 
 
 secondary, 361, 368 
 
 verrucous, 246 
 Elephantiastic lupus, 554 
 Emotional erythema, 28 
 
 roseola, 25 
 Endodermophytons, 528 
 Ephelides, 323 
 Ephidrosis, 443 
 
756 
 
 INDEX 
 
 Epidermic cysts, 670 
 
 traumatic, 671 
 
 nail, 431 
 
 papules, 127 
 
 pemphigus of newborn, 168 
 
 pustules, 161 
 Epidermolysis hereditaria bullosa, 
 Epidermomycoses, 515 
 Epidermophytes, 515 
 Epidermophytosis, 114, 216, 522 
 Epiphenomena, 175 
 EpitheUal cancers, 676 
 
 tumors, 669 
 Epithelioma, 676 
 
 baso-eellular, 679 
 
 of buccal cavity, 309 
 
 calcified, 679 
 
 cancroid, 677 
 
 cellular, 676 
 
 flat cicatricial, 338, 681 
 
 metastatic, 683 
 
 nevo-cellular, 682 
 
 pagetoid, 681 
 
 papillary, 677 
 
 papillomatous, 249 
 
 proliferating, 249 
 
 spinocellular, 676 
 
 terebrans, 682 
 
 treatment of, 687 
 
 tubular, 679 
 
 proliferative, 682 
 Epitheliomatosis pigmentosa, 355 
 Epizoa, 502 
 Equine scabies, 120 
 Ergotism, 316 
 Erosions of tongue, 304 
 Erosive ulcers, 676 
 Eruptions, alimentary, 479 
 
 autotoxic, 479 
 
 diabetic, 480 
 
 feigned^ 471 
 
 medicinal, 463, 472 
 
 serum, 477 
 
 toxic, 472 
 Eruptive dermatoses, 17 
 
 xanthoma, 698 
 Erysipelas, gangrenous, 319 
 Erysipeloid eczema, 71 
 Erythema, 23 
 
 active, 24 
 
 of alimentary origin, 27 
 
 annulare, 26 
 
 associated, 23 
 
 atrophicans, 343 
 
 autotoxic, 28 
 
 balsamic, 473 
 
 bullous, 24 
 
 centrifugum, 570, 571 
 
 desquamative, 24 
 
 emotional, 28 
 
 figured, 25 
 
 a i'rigore, 27 
 
 Erythema induratum, 564 
 of Bazin, 274 
 of young girls, 25 
 
 infantile gluteal. 31 
 
 infectious, 27, 28 
 
 intertrigo, 27 
 191 marginatum, 26 
 
 multiforme, 39 
 
 nodosum, 265 
 
 nodular, 24 
 
 papular, 24 
 
 papulo-erythematous, 39 
 
 papulo-lenticular, 31 
 
 passive, 24 
 
 in patches, 25 
 
 pathogenic, of Bazin, 27 
 
 pellagrous, 32 
 
 pernio, 34 
 
 perstans, 26, 572 
 
 pigmented, 24 
 
 polymorphous, bullous, 175 
 
 a, pudore, 28 
 
 purpuric, 24 
 
 recurrent desquamative scarlatini- 
 form, 25, 116 
 
 reflex, 28 
 
 rubeoliform, 25 
 
 scarlatiniform, 25 
 
 scarlatinoid, 25 
 
 simple, 24 
 
 solare seu actinicum, 32 
 
 squamous, 24 
 
 treatment of, 426 
 
 urticarial, 24 
 
 vesicular, 24 
 Erythemato-atrophic tuberculides, 564 
 Erythemato-follicular lupus, 570 
 Erythemato-papular syphilides, 142 
 Erythemato-squamous dermatoses, 89 
 Erythemato-squamous epidermo-my- 
 
 coses, 114 
 Erythemato-tuberculous lupus, 555 
 Erythematoid lupus, 228, 554 
 Erythematous syphilides, 620 
 
 tuberculides, 564 
 Erythrasma, 114, 532 
 Erythroderma, ichthyosiform, 203 
 Erythrodermas, 23, 115 
 
 congenital, 122 
 
 desquamative, of nurslings, 124 
 
 leukemic, 119 
 
 of newborn, 122 
 
 premycotic, 119 
 
 primary, 116, 117, 118 
 
 secondary, 120 
 Erythrodermic dermatoses, 120 
 
 eczematides, 95 
 
 tuberculides, 564 
 Erythromelia, 344 
 Erythrosis facialis, 37 
 Espundia, 650 
 Esthiomene, 311 
 
INDEX 
 
 757 
 
 Ethereal solutions, 714 
 Excoriation of tongue, chronic super- 
 ficial, 229 
 Exfoliative areata, 228 
 
 dermatitis of nurslings, 123 
 Extragenital chancre, 282, 616 
 Exudative eczema, 71 
 
 Face, eczema of, 75 
 
 herpes of, 153 
 Facial hemiatrophy, 354 
 Fades leonina, 583 
 Factitious urticaria, 49 
 Farcy, 591 
 Fatty bodies, 716 
 Favus, 420, 516 
 
 alopecic, 421 
 
 cutaneous, 114 
 
 of glabrous skin, 518 
 
 impetiginous, 421 
 
 of nails, 518 
 
 pityriasic, 421 
 
 squamous, 420 
 
 treatment of, 426 
 
 urceolaris, 420 
 Feigned eruptions, 471 
 Fetal ichthyosis, 124 
 Fetus, harlequin, 124 
 Fibroma, 689 
 
 molluscum, 667 
 Figured eczematides, 92 
 Filaria medinensis, 514 
 Filarial elephantiasis, 361, 369, 515 
 Filariasis, 369 
 Fissured eczema, 66 
 Flat angiomas, 693 
 
 senile warts, 208 
 
 vascular nevi, 693 
 
 warts, 127 
 Fleas, 506 
 
 Flores unguium, 438 
 Fluxus sebaceus, 384 
 Follicles, pilo-sebaceous, 376 
 Folliclis, 398, 566 
 Follicular cysts, 671 
 
 eczematides, 395 
 
 ichthyosis, 403 
 
 keratosis, 401, 403 
 
 pustules, 160 
 
 syphilides, 396 
 
 tuberculides, 398 
 Folliculite conglomeree en placards, 382 
 
 epilante, 394 
 Folliculitides, acute suppurative, 377 
 
 cicatricial depilating, 392 
 
 subacute, 395 
 
 trichophytic, 380 
 Folliculitis agminata, 382, 522 
 
 chancroidal, 597 
 
 decalvans, 394 
 
 Folliculitis rubra, 402 
 Folliculoses, 376, 377 
 Forearms, eczema of, 75 
 Fox, Tilbury, impetigo of, 162 
 Frambesia Brasiliana, 650 
 
 tropica, 250, 646 
 Freckles, 323 
 
 infective melanotic, 665 
 Frontal scleroderma, 351 
 Frost-bite, 34, 452, 564 
 
 of first degree, 34 
 
 of second degree, 34 
 Fungoid tuberculosis, 552 
 Furfuracea, 409 
 Furunculus, 540 
 
 orientalis, 648 
 
 Gafsa boil, 648 
 Gangrene, buccal, 308 
 carbolic, 314 
 cutaneous, 312 
 diabetic, 316 
 direct local, 313 
 dry, 312 
 
 fulminating, of genital organs, 319 
 moist, 312 
 
 multiple, of adults, 318 
 cachectic of skin, 317 
 of children, 317 
 through changes in blood, 316 
 traumatic, 313 
 of vascular origin, 315 
 Gangrenous dermatitis of children, 317 
 ecthyma, 317 
 erysipelas, 319 
 pemphigus, 187 
 urticaria, 317 
 varicella, 171, 317 
 Gastro-intestinal purpura, 55 
 Genital chancre, 616 
 diabetides, 480 
 herpes, 310 
 
 mucosa, soft chancre of, 310 
 syphilitic chancre of, 311 
 traumatic excoriations of, 310 
 tuberculous ulcer of, 311 
 ulcerations of, 310 
 organs, gangrene of, fulminating, 
 319 
 granuloma of, ulcerative, 251 
 Genito-crural zona, 156 
 Geographical tongue, 228 
 Giant chancre, 615 
 
 urticaria, 49 
 Gift-spots, 438 
 Glanders, 590 
 acute, 591 
 chronic, 592 
 mutilating, of face, 592 
 
758 
 
 INDEX 
 
 Glanders, pustules of, 173 
 
 ulcerations of, 293 
 Glandular lymphadenoma, regional, 653 
 Glossitis, deep, 226 
 
 exfoliativa marginata, 228 
 
 median rhomboidal, 226 
 
 of nervous arthritics, 228 
 • sclerotic, 226 
 
 syphilitic. 225 
 Glossodynia, 488 
 Gluteal erythema, infantile, 31 
 Glycerine, 715 
 Glycosuric xanthoma, 699 
 Gonococcal keratoderma, 216 
 
 keratoma, 210 
 Gonorrhea, erosions in, 310 
 Gout, tophi of, 702 
 Granuloma annulare, 261 
 
 favosum, 517 
 
 fungoides, 657 
 
 of genital organs, ulcerative, 251 
 
 inguinale, 251 
 
 pyogenicum, 704 
 
 trichophyticum, 522 
 
 venereo, 251 
 Granulosis rubra nasi, 443 
 Green cancer, 653 
 Groin ulceration, 251 
 Ground-itch, 515 
 Gummas, 266 
 
 dermic, 267 
 
 hypodermic, 267 
 
 leprous, 272 
 
 mycotic, 270 
 
 scrofulo-tubercular, 268 
 
 sporotrichotic, 270 
 
 syphilitic, 267 
 
 of palatine velum, 268 
 of tongue, 268 
 
 tuberculous, 268, 550 
 Gummous infiltrations of leprosy, 272 
 Gutta rosea, 36 
 
 Haihy nevi, 668 
 
 regions, pruritus of, 488 
 Hamartoma, 359 
 Hands, eczema of, 75 
 Hang nails, 432 
 Harlequin fetus, 124 
 Head-lice, 502 
 Heat-stroke, 32 
 Hebra, acne varoliformis of, 391 
 
 eczema marginatum of, 524 
 Hebra's prurigo, 494 
 Helconyxis, 437 
 Hemangioma, 693 
 Hematidrosis, 444 
 Hematogenous pruritus, 485, 487 
 Hemiatrophy, facial, 354 
 
 Hemorrhagic pemphigus, 187 
 
 urticaria, 44 
 
 zona, 155 
 Hemosiderin, 320 
 Herpes, 150 
 
 buccal, 152, 304 
 
 circinatus, 66, 114, 522 
 
 conjunctivalis, 153 
 
 cretaceus, 570 
 
 genital, 150, 310 
 
 gestationis, 184, 185 
 
 iris, 176 
 
 malignant, 122 
 
 of pharynx, 152 
 
 progenitalis, 150 
 
 recurrent, 153 
 
 tonsurans maculosus, 93, 99 
 
 ulcerated, 284 
 
 vacciniform, 168 
 
 zoster, 154. See Zona. 
 Herpetic angina, 152 
 Herpetide, benign, 122 
 Herpetiform syphilides, 398 
 Hidradenomata, 673 
 Hidrocystoma, 672 
 Hidrosadenitis, 446, 544 
 
 suppurativa disseminata, 566 
 Hidroses, 441 
 
 functional, 442 
 
 organic, 445 
 Hutchinson's teeth, 628 
 Hydradenitis destruens suppurativa, 
 
 566 
 Hydrargyria, cutaneous, 465 
 Hydroa, 25, 175 
 
 Bazin's, 176 
 
 buccal, 177, 304 
 
 herpetiforme, 179 
 
 puerporum, 185 
 
 vacciniforme, 185 
 Hyperchromia, 320 
 Hyperidrosis, 442 
 
 nudorum, 443 
 
 oleosa, 443 
 Hyperkeratoses, 194 
 
 congenital, 203 
 diffuse, 124 
 
 ichthyosiform, 124, 203 
 Hyperkeratotic eczema, 64 
 
 nevi, 206 
 
 verrucose nevi, 667 
 Hypertrichoses, 404 
 
 fetalis, 406 
 
 regional, 407 
 Hypertrophic acne, 375 
 
 chancre, 615 
 
 dermatoses, 361 
 
 lichen corneus, 140, 247 
 
 mucous patches, 247 
 Hypertrophies, cutaneous, 360 
 
 non-elephantiastic, 371 
 Hypodermic gummas, 267 
 
INDEX 
 
 759 
 
 Hypodermic sarcoids, 273 
 tubercles, 252 
 tuberculides, 564 
 
 Ichthyosiform congenital erythro- 
 derma with hyper-epidermatro- 
 phy, 204 
 
 erythroderma, 203 
 
 hyperkeratosis, 124, 203, 205 
 Ichthyosis, 200 
 
 anserina scrofulosorum, 402 
 
 buccal, 219 
 
 congenital, 124 
 
 cornea, 200 
 
 fetal, 124 
 
 follicularis, 403 
 
 hystrix, 202 
 
 nitida, 202 
 
 sauriasis, 205 
 
 senile, 202 
 
 tabescentium, 202 
 Idiopathic atrophies, 343, 344 
 
 zona, 158 
 Impetiginization, 64 
 Impetiginous eczema, 64, 71, 72 
 
 favus, 421 
 
 lupus, 556 
 
 onyxis, 434 
 
 stomatitis, 167 
 Impetigo, 162 
 
 of Bockhardt, 167 
 
 bullous, 168, 178 
 
 contagiosa, 167 
 
 figurata, 166 
 
 granulata, 166 
 
 herpetiformis, 185 
 
 larvalis, 166 
 
 miliary, 87 
 
 of mucous membranes, 167 
 
 sparsa, 166 
 
 staphylococcic, 167 
 
 streptococcic, 162 
 
 of Tilbury Fox, 162 
 
 vulgaris, 165 
 Infantile eczema, 65, 80 
 
 gluteal erythema, 31 
 
 vacciniform dermatitis, 168 
 Infected eczema, 64 
 Infectious dermatoses, 535 
 bacillary, 546 
 due to protozoa, 610 
 
 urticaria, 46 
 Intercostal zona, 156 
 Interstitial vesiculation, 148 
 Intertrigo, 30 
 Intertrigo-eczema, 30 
 
 of infants, 75 
 Intertrigo-erythema, 30 
 Ioderma bullosum, 177 
 
 Ioderma tuberosum, 476 
 Iodide acne, 475 
 
 pemphigus, 475 
 Iris, herpes of, 176 
 Isolation, 32 
 Itching, 481 
 Ixodes, 514 
 
 J 
 
 Jadassohn, anetoderma erythemato- 
 
 sum of, 345 
 Jigger, 506 
 Juvenile flat warts, 130, 241 
 
 " Kartenblattaehnliche morphoea," 
 
 346 
 Keloid acne, 391 
 Keloids, 690 
 Keratoderma, 195, 211 
 
 essential, 211 
 
 familial, 211 
 
 gonococcal, 216 
 
 occupational, 213 
 
 symmetrical, of adults, 212 
 
 symptomatic, 213 
 Keratodermic syphilides, 619 
 Keratoma, diffuse congenital malig- 
 nant, 124 
 
 gonococcal, 210 
 
 palmare et plantare, 211 
 Keratosis, 194 
 
 arsenical, 213 
 
 circumscribed, 195, 206 
 
 diffuse, 195 
 
 follicular, 401, 403 
 
 generalized, 195 
 
 of mucosae, 195 
 
 of mucous membranes, 218 
 
 pilaris rubra atrophicans of face, 
 402 
 simplex, 402 
 
 punctiform, 216 
 
 regional, 195 
 
 senilis, 209 
 Keratotic eczema, 72 
 
 nevi, 206 
 Kerion of Celsius, 382, 522 
 Kerosis, 37, 196 
 Kerotic alopecias, 408 
 Koch's phenomenon, 548 
 Koilonychia, 437 
 Kraurosis vulvae, 354 
 
 Lamellar desquamation of newborn, 
 122 
 eczema, 64 
 Lanuginous pseudohypertrichosis, 406 
 
760 
 
 1XDEX 
 
 Larva migrans, 515 
 Lazarine leprosy, 58(5 
 Legs, eczema of, 75 
 
 varicose ulcers of, 296 
 Leishmanioses, 648 
 Lenticular papular syphilides, 129, 142 
 
 syphilides, til!) 
 Lentigines, 665 
 Lentiginosis profusa, 665 
 Lentigo, 665 
 
 maligna, 665 
 Leontiasis, 365 
 
 leprosa, 583 
 Lepra maculosa, 585 
 
 nervorum, 585 
 
 tuberosum, 583 
 Leprides, 581, 588 
 Lepromas, 258 
 Lepromata, 587 
 Leprosy, 578 
 
 dyschromias of, 327 
 
 gummous infiltrations of, 272 
 
 lazarine, 586 
 
 mixed form of, 587 
 
 morpha? of, 332 
 
 "rat," 579 
 
 tubercles of, 258 
 
 tubercular, 583 
 
 ulcerations of, 292 
 Leprous gummas, 272 
 
 infiltrations, 258 
 
 morphea, 258 
 
 nodosities, 271 
 Leptothrix of Wilson, 428 
 Leptus autumnalis, 513 
 Leuconychia, 438, 653 
 Leukemia, cutaneous, 651 
 
 lymphatic, 651, 652 
 
 myeloid, 651, 652 
 
 treatment of, 661 
 Leukemic erythroderma, 119 
 Leukoderma, 321, 331 
 Leukokeratosis, 219 
 Leukomelanodermas, 331, 332 
 Leukonychia totalis, 438 
 Leukoplakia, 219 
 
 and cancer, 221 
 
 ulcerations of, 307 
 
 vulvar, 220 
 Leukotrichia, 416 
 Lichen, acute, 134 
 
 annulatus, 133 
 
 serpiginosus, 90 
 
 circumscriptus, 90 
 
 corneus, hypertrophic, 140, 247 
 
 ferox, polymorphous, 495 
 
 gyratus, 90 
 
 marginatus seu serpiginosus, 133 
 
 nitidus, 564 
 
 pilaris, 402 
 
 planus, 131 
 acute, 120 
 
 Lichen planus, atrophic, 137, 332, 339 
 moniliformis, 139 
 of mucous membranes, 227 
 nitidus, 138 
 obtusus, 139 
 sclerotic, 137 
 
 scleroticus vel atrophicus, 463 
 treatment of, 136 
 verrucosus, 140 
 psoriasis, 112 
 rubra acuminatus, 399 
 bullosus, 134 
 planus, 131 
 scrofulosorum, 145, 564 
 simplex, 492, 498 
 spinulosus, 403 
 striatus, 133 
 urticus, 492 
 Wilson's, 131 
 zoniformis, 133 
 Lichenified eczema, 71, 72 
 Lichenization, 490 
 Lichenoid eczema, 64 
 syphilides, 396 
 
 trichophytosis, disseminated, 522 
 tuberculide, 146, 564 
 Linear atrophies, 341 
 
 nevi, 206 
 Lipoma, 691 
 Livedo, 36 
 
 annularis, 26, 36 
 Liver spots, 664 
 Lobular epithelioma, 676 
 Lues venerea, 610 
 Lumbo-abdominal zona, 156 
 Lupoid acne, 394 
 
 sycosis of Brocq, 394 
 Lupoids, 272 
 benign, 259 
 
 disseminated miliary, 259 
 nodular, 260 
 tubercles, 259 
 Lupoma, 553 
 Lupus, 553 
 
 acneiform, 570 
 agminatus, 554 
 angiomatous, 554 
 colloid, 554 
 confluens, 554 
 diffusus, 554 
 disseminatus, 554 
 elephantiastic, 554 
 elevatus, 554 
 erythematodes, 228, 568 
 discoides, 570 
 disseminatus, 566 
 exanthematicus, 564, 572 
 migrans, 571 
 treatment of, 573 
 erythematoid, 554 
 erythemato-follicular, 570 
 erythemato-tuberculous, 555 
 
Index 
 
 761 
 
 Lupus exedens, 555 
 
 hypertrophicus, 554 
 
 impetiginous, 556 
 
 macular, 554 
 
 non-exedens, 554 
 
 papillomatous, 554 
 
 phagedenicus, 555 
 
 planus, 554 
 
 psoriatiform, 554 
 
 pustular, 173, 555 
 
 resolutus, 554 
 
 scleroticus, 554 
 
 serpiginous, 555 
 
 squamous, 554 
 
 treatment of, 561 
 
 tubercle, 553 
 
 tumidus, 554 
 
 ulcerations, 290 
 
 ulcerative vegetative, 555 
 
 vorax, 555 
 
 vulgaris, 553 
 Lymphadenia, cutaneous, 657 
 Lymphadenoma, regional glandular, 
 
 653 
 Lymphangiectases, 696 
 Lymphangioma, 695 
 Lymphangitis, sporotrichotic gum- 
 mous, 270 
 
 tuberculous gummous, 269 
 Lymphatic leukemia, 651 
 
 varicosities, 696 
 Lymphoderma perniciosa, 119 
 Lymphogranulomatosis, 653 
 Lymphorrhea, 362 
 Lymphosarcoma, 653 
 Lymph-scrotum, 363 
 
 Microglossia, congenital, 370 
 Macular atrophies, 341 
 Macules, 23, 322 
 Madura foot, 270, 602 
 Madurella, 599 
 Mai del Pinto, 528 
 Malassezia furfur, 529 
 Malgache, 301 
 Malignant edema, 594 
 
 pustule, 593 
 Malleus, 590 
 Malum perforans, 302 
 of mouth, 308 
 plantaris, 303 
 Mechanical purpura, 54 
 Medicinal acne, 390 
 
 eruptions, 463, 472 
 
 roseola, 25 
 Meige, trophedema of, 371 
 Melanin, 320 
 Melanodermas, 325 
 
 Addisonian, 325 
 
 Melanodermas, pediculous, 329 
 
 phthiriasic, 329 
 
 tuberculous, 325 
 Melanosis lenticularis progressiva, 355 
 
 precancerous circumscribed, 665 
 
 progressive cutaneous, 665 
 Meleda disease, 271 
 Mendacia, 438 
 Mercurial stomatitis, 308 
 Microbic eczema, 66 
 Microsporia, 527 
 Microsporon Audouini, 527 
 
 furfur, 530 
 
 minutissimum, 532, 533 
 Microsporosis, 114 
 Miliaria crystallina, 445 
 Miliary abscess of little children, 446 
 
 colloid degeneration of cutis, 359 
 
 impetigo, 87 
 
 syphilides, 619 
 
 tuberculosis of skin and mucous 
 membranes, 549 
 Milium, 385, 671 
 Milks, 717 
 
 Moist erosions of buccal mucosa, 304 
 Molluscum contagiosum, 674 
 
 pendulum, 667 
 Monilithrix, 418 
 Morbus maculosus, 57 
 Morphse gutta, 346 
 
 of leprosy, 332 
 
 nostras, 332 
 Morphea, 350 
 
 leprosa, 582 
 Morphology of the dermatoses, 17, 
 
 23 
 Mosquitoes, 507 
 Mouth, herpes of, 153 
 
 malum perforans of, 308 
 
 syphilitic chancres of, 307 
 
 "trench," 306 
 
 ulcers of, trophic, 308 
 Mozambique ulcers, 301 
 Mucous membranes, impetigo of, 167 
 keratosis of, 218 
 lichen planus of, 227 
 lupus of, 558 
 ulcerations of, 303 
 zona of, 157 
 
 patches, 144, 620 
 
 hypertrophic, 247 
 Muguet, 305 
 Mycetoma, 270, 602 
 Mycoses, papillomatous, 249 
 Mycosis fungoides, 657 
 Mycotic gummas, 270 
 Myeloid leukemia, 651 
 Myelomatosis, 652 
 Myoma, 692 
 Mythomania, 193 
 Myxedema, 372 
 Myxoma, 692 
 
762 
 
 INDEX 
 
 N 
 
 Nail, epidermic, 431 
 Nail-plate, 430 
 
 Nails, congenital malformations of, 
 431 
 
 diseases of the, 430 
 
 eczema of, 435 
 
 hang, 432 
 
 worn-off, 432 
 Nasal pruritus, 488 
 " Necklace of Venus," 326 
 Necrobiosis, 312 
 Necrosis, 312 
 Neoplasms of buccal cavity, ulcerative, 
 
 309 
 Nervous diseases, dyschromias of, 327 
 
 pruritus, 485, 487 
 Neuro-arthritic pseudo-elephantiasis, 
 371 
 
 pseudolipoma, 371 
 Neurodermatoses, 481 
 Neuro-fibromatosis, 668 
 Neuromas, plexiform, 667 
 Nevi, 664 
 
 achromic, 320 
 
 adenomatous, 672 
 
 cellular, 666 
 
 cystic follicular adenomatous, 671 
 
 hairy, 668 
 
 hyperkeratotic, 206 
 
 keratotic, 206 
 
 linear, 206 
 
 molluscum, 667 
 
 pigmentary, 665 
 
 pilosi, 405 
 
 tuberous, non-vascular, 666 
 
 varicose, 206 
 
 vascular, 23, 693 
 
 verrucose, 666, 667 
 Nevo-carcinomata, 667, 682 
 Nevo-cellular epitheliomas, 682 
 Newborn, erythrodermas of, 122 
 
 lamellar desquamation of, 122 
 Nile boil, 648 
 Nipple, eczema of, 75 
 
 Paget's disease of, 234 
 Nits, 502 
 Nocardia, 599 
 Nodes, 263 
 
 subacute non-gummous, 271 
 Nodular dermatoses, 263, 265 
 
 erythema, 24 
 
 lupoid, 260 
 
 syphilides, 271 
 Nodules, 263 
 Noma, 308 
 
 Non-cicatricial alopecias, 412 
 Non-elephantiastic hypertrophies, 371 
 Nosology of the dermatoses, 447 
 Nummular eczema, 72 
 
 syphilides, 619 
 
 Nurslings, desquamative erythroder- 
 ma of, 124 
 exfoliative dermatitis of, 123 
 
 Occlusive dressings, 717 
 Occupational acne, 390 
 
 dermatitides, 467 
 
 eczema, 65, 467 
 
 keratoderma, 213 
 
 radiodermatitides, 454 
 Oidium, 599 
 One-year boil, 648 
 Onychogryphosis, 431, 43S 
 Onychophagia, 432 
 Onychomycosis, 433 
 
 favosa, 433 
 
 trichophytica, 433, 522 
 Onychorrhexis, 439 
 Onychoschizia, 439 
 Onychoses, 430 
 
 of the dermatoses, 434 
 
 dystrophic, 437 
 
 of general diseases, 436 
 
 of nervous origin, 437 
 
 traumatic, 432 
 Onyxis, impetiginous, 434 
 
 pyococcic, 434 
 
 syphilitic, 436 
 Opaline plaques, 620 
 Ophiasis, 413 
 Ophthalmic zona, 156 
 Orbicular eczema, 75 
 Oriental boil, 250, 648 
 Orificial eczema, 75 
 Oroya fever, 593 
 
 Pachydermatocele, 372 
 Pachydermic cachexia, 372 
 Pachyonyxis, 437 
 Pagetoid epithelioma, 681 
 Paget's disease of nipple, 234 
 Palatine velum, svphilitic gummas of 
 
 268 
 Palmar pruritus, 488 
 
 psoriasis, 215 
 
 syphilides, psoriatiform, 216 
 
 trichophytosis, 216 
 Paludean pigment, 320 
 Panighao, 515 
 Papillary dystrophy, 242 
 
 epithelioma, 677 
 Papillomata, 670 
 Papillomatous dermatoses, 238 
 
 elephantiasis, 246 
 
 epithelioma, 249 
 
 lupus, 554 
 
INDEX 
 
 763 
 
 Papillomatous mycoses, 249 
 
 sporotrichoses, 249 
 
 toxicodermas, 249 
 
 tuberculosis, 247 
 Papular chancre, 615 
 
 dermatoses, 127 
 
 erythema, 24 
 
 patches, 127 
 
 plaques, 127 
 
 roseola, 142 
 
 syphilides, 142, 619 
 
 urticaria, 45 
 Papules, 127 
 
 dermic, 128 
 
 epidermic, 127 
 
 mixed, 129 
 
 of prurigo, 140, 141 
 
 of strophulus, 141 
 Papulo-circinate syphilide, 144 
 Papulo-erythematous erythema, 39 
 Papulo-lenticular erythema, 37 
 Papulo-ne erotic tuberculides, 398, 566 
 Papulo-nummular syphilides, 144 
 Papulo-pustular follicular syphilides,398 
 Papulo-pustules, 160 
 Papulo-squamous follicular syphilides, 
 397 
 
 syphilide, 142 
 
 tuberculide, 147 
 Papulo-tubercles, 252 
 Papulo-vesicular eczema, 72 
 Paraffinoma, 276 
 Parakeratosis, 64 
 
 variegata, 112 
 Parapsoriasis, 111 
 
 guttata, 111 
 
 lichenoides, 111 
 
 in plaques, 112 
 Parapsoriatic tuberculides, 564 
 Parasites, animal, 502 
 
 vegetable, 502 
 Parasitic dermatoses, 502 
 
 eczema, 65 
 
 trichoses, 419 
 Parasitophobia, 482 
 Paratraumatic eczema, 66, 73 
 Parchment-like scleroderma, 346 
 Parenchymatous vesiculation, 148 
 Pastes, 717 
 
 Pathogenic erythema of Bazin, 27 
 Pathomania, 193 
 Pediculoides ventricosus, 514 
 Pediculosis, 502 
 Pediculous melanoderma, 329 
 Pediculus pubis, 505 
 Pellagra, 32 
 Pemphigus acutus febrilis gravis, 179 
 
 chlorotic, 192 
 
 chronic, 186, 188 
 
 congenital, 191 
 
 with tendency to cicatrization 
 191 
 
 Pemphigus diphtheroid, 187 
 epidermic, of newborn, 168 
 foliaceus, 120, 189 
 gangrenous, 187 
 hemorrhagic, 187 
 hystericus, 192 
 iodide, 475 
 pruriginous, 179 
 recurrent, 179 
 
 simple traumatic hereditary, 191 
 successif a Kystes epidermiques, 
 
 191 
 syphilitic, 177 
 treatment of, 189 
 ulcerative, 187 
 vegetans, 244, 245 
 virginal, 192 
 vulgaris, 186 
 with small bullae, 179 
 Peribuccal pruritus, 488 
 Perigenital pruritus, 488 
 Perionyxis, 435 
 Peripheral zona, 156 
 Peripilar eczematides, 95 
 
 seborrheids, 395 
 Perleche, 540 
 
 Phagedena, chancroidal, 295 
 tertiary, 295 
 ulcerations of, 293 
 Phagedenic ulcers, 281 
 
 of tropical countries, 301 
 Pharynx, herpes of, 152 
 Phlegmonous acne, 386 
 hidrosadenitis, 446 
 Phlyctenoses, recurrent, of extremities, 
 
 186 
 Phthiriasic melanoderma, 329 
 Phthiriasis, 502 
 Phthirius inguinalis, 505 
 Phthisis, acute buccal, 289 
 Pian, 646 
 Pian-Bois, 649 
 Piedra, 428 
 Pigeonneau, 469 
 
 Pigmentary dermatosis of legs, 323 
 
 dystrophy, 242 
 
 spots, 323, 325 
 
 syphilides, 326 
 
 Pigmentations, artificial, 321 
 
 Pigmented erythema, 24 
 
 urticaria, 44 
 Pigments, cutaneous, 320 
 Pilo-sebaceous follicles, 376 
 Pinta, 528 
 
 Pityriasic erythroderma in dissemin- 
 ated patches, 173 
 favus, 421 
 Pityriasiform eczematides, 93 
 Pityriasis capitis, 198 
 circinata, 90 
 
 lichenoides chronica, 112 
 maculata et circinata, 99 
 
764 
 
 INDEX 
 
 Pityriasis oleosa, 199 
 . rosea, 99, 198 
 
 rubra, 118, 198 
 
 pilaris, 120, 198, 399, 564 
 
 sicca, 199 
 
 simplex, 147, 198 
 
 of face and hairless parts, 200 
 
 versicolor, 198, 529 
 Pityroid alopecias, 409 
 Plantar pruritus, 488 
 
 psoriasis, 215 
 
 syphilides, psoriatiform, 216 
 
 trichophytosis, 216 
 
 warts, 241 
 Plexiform neuromas, 667 
 Plica, 503 
 Poikiloderma vascularis atrophicans, 
 
 344 
 Polyadenomas, 676 
 Polymorphous acne, 386 
 
 dermatitis, 179 
 
 erythema, bullous, 175 
 Porokeratosis, 210, 216 
 Port-wine stains, 664, 693 
 Posterosive syphiloid, 31 
 Postsyphilitic atrophies, 342 
 Powders, 714 
 Pox, 610 
 
 Precancerous affections, 236, 685 
 Premycotic erythroderma, 119 
 Presenile dystrophy, 358 
 Progressive multiple angiomas, 694 
 Proliferating dermatoses, accidentally, 
 244 
 
 epithelioma, 249 
 
 pyodermatitides, 246 
 
 tropical dermatoses, 249 
 Prurigenetic mnemoderma, 485 
 
 summation, 485 
 Pruriginous pemphigus, 179 
 Prurigo, 488 
 
 circumscripta, 498 
 
 ferox, 495 
 
 Hebra's, 494 
 
 hiemalis, 497 
 
 lymphadenique, 495 
 
 nodularis, 495 
 
 papules of, 140, 141 
 
 simplex acutus, 492 
 
 summer, 498 
 
 treatment of, 499 
 
 vulgaris, 496 
 Pruritus, anal, 488 
 
 artificial, 482 
 
 biopsic, 487 
 
 buccal, 488 
 
 diathetic, 484 
 
 dyscratic, 484, 487 
 
 of hairy regions, 488 
 
 hematogenous, 485, 487 
 
 hiemalis, 484 
 
 localized, 488 
 
 Pruritus, nasal, 488 
 
 nervous, 485, 487 
 
 palmar, 488 
 
 peribuccal, 488 
 
 perigenital, 488 
 
 primary, 483 
 
 plantar, 488 
 
 secondary, 482 
 
 senile, 488 
 
 toxic, 484 
 
 treatment of, 499 
 
 vulvar, 488 
 
 winter, 484 
 Pseudococcidias, 231 
 Pseudo-elephantiasis, neuro-arthritic, 
 
 371 
 Pseudolipoma, neuro-arthritic, 371 
 Pseudo-pelade of Brocq, 393 
 Pseudoxanthoma elasticum, 358 
 Psoriasis, 102 
 
 arthropathia 105 
 
 buccal, 219 
 
 discoides, 102 
 
 dolorosa, 105 
 
 guttata, 102 
 
 infiltrated, 104 
 
 inversa, 105 
 
 inveterata, 104 
 
 lichen, 112 
 
 nummularis, 102 
 
 oozing, 104 
 
 palmar, 215 
 
 plantar, 215 
 
 punctata, 102 
 
 syphilitic, 216 
 
 treatment of, 109 
 
 universalis, 120 
 Psoriatiform eczema, 64 
 
 eczematides, 95 
 
 lupus, 554 
 
 syphilides, 113, 216 
 Psorospermosis follicularis vegetans, 
 
 231 
 Pulex penetrans, 506 
 Punctiform keratosis, 216 
 Purpura, 52 
 
 of acute infectious diseases, 54 
 
 annularis telangiectodes, 56 
 
 cachectic, 54 
 
 exanthemata, 55 
 
 fulminans, 57, 317 
 
 gastro-intestinal, 55 
 
 hemorrhagica, 53, 57 
 
 mechanical, 54 
 
 primary, 54, 75 
 
 rheumatoid, 54 
 
 secondary, 54 
 
 senilis, 54 
 
 simplex, 53 
 
 toxic, 54 
 
 urticans, 44 
 Purpuric erythema, 24 
 
INDEX 
 
 765 
 
 Purpuric fever, 59 
 Pustular dermatoses, 161 
 
 lupus, 173, 555 
 Pustules, 160 
 
 dermic, 160 
 
 epidermic, 160 
 
 follicular, 160 
 
 of infectious chronic dermatoses, 
 172 
 Pyococci, 536 
 Pyococcic onyxis, 434 
 Pyodermatitides, 467, 536 
 
 proliferating, 246 
 
 Radiodermatitides, 452 
 
 "Rat leprosy," 579 
 
 Recklinghausen's disease, 668 
 
 Recurrent pemphigus, 179 
 
 Red tongue, 228 
 
 Reducing agents, 734 
 
 Reflex erythema, 28 
 
 Regional glandular lymphadenoma, 653 
 
 Reticular atrophy, 344 
 
 Rheumatic nodosities, 266 
 
 Rheumatoid purpura, 54 
 
 Rhinophyma, 374 
 
 Rhinoscleroma, 373 
 
 Rhomboidal glossitis, median, 226 
 
 Rodent ulcer, 281, 682 
 
 Rosacea, 36 
 
 Roseola, antipyrin, 42 
 
 balsamic, 42 
 
 emotional, 25 
 
 of leprosy, 42 
 
 medicinal, 25 
 
 of mycosis fungoides, 42 
 
 papular, 142 
 
 squamosa, 99 
 
 symptomatic infectious, 25 
 
 syphilitic, 41 
 Roseolar exanthematic fevers, 25 
 Rouget, 513 
 
 Rubeoliform erythema, 25 
 "Run-around," 163 
 
 S 
 
 Saccharomyces, 599 
 Salek boil, 648 
 Salve sticks, 716 
 Salves, 716 
 Sarcoids, 259, 272 
 
 benign, 259, 272, 564 
 
 disseminated nodular, 273, 564 
 
 hypodermic, 273 
 
 subcutaneous, 564 
 Sarcoma, 706 
 
 atypical, 706, 708 
 
 Sarcoma, fascicular, 706 
 
 generalized, 707 
 
 multiple hemorrhagic, 709 
 
 primary idiopathic, 706 
 
 round-cell, 706, 707 
 
 secondary metastatic, 706 
 
 spindle-cell, 706 
 
 typical, 706 
 Scabies, 507 
 
 animal, 512 
 
 equine, 120, 512 
 
 Norwegica, 512 
 Scabitees ungium, 437 
 Scaborrhea, fatty, 383 
 Scalp, eczema of, 74 
 Scarlatiniform erythema, 25 
 
 recurrent desquamative, 25 
 Sclerema, 347 
 Sclerodactylia, 348 
 Scleroderma, 347 
 
 annular, 352 
 
 in bands, 351 
 
 edematous, 347 
 
 frontal, 351 
 
 generalized, 347 
 
 parchment-like, 346 
 
 partial, 350 
 
 in patches, 350 
 
 progressive, 348 
 
 superficial circumscribed, 346 
 Sclero-gummous ulcerations, 288 
 Scleronychia, 431 
 Sclerosis, cutaneous, 334 
 Sclerotic atrophies in spots, 346 
 
 dermatoses, 335 
 
 lichen planus, 137 
 Scrofuloderma, 268 
 Scrofulo-tubercular gummas, 268 
 Scrofulous ecthyma, 170 
 Scrotal tongue, 226 
 Scurvy, infantile, 55 
 
 sporadic, 55 
 Sebaceous cysts, 670 
 
 flux, 383 
 Seborrhea, 383 
 
 congestiva, 570 
 
 corporis, 90 
 
 sicca, 198 
 
 steatosa, 383 
 Seborrheal eczema, 63 
 
 syphilides, 144 
 
 warts, 208 
 Seborrheic alopecias, 409 
 
 cocoon, 383 
 
 filament, 383 
 
 oleosa, 384 
 
 utriculus, 383 
 Seborrhoids, 91 
 Senile degeneration, 357 
 
 eczema, 65 
 
 pruritus, 488 
 
 purpura, 54 
 
766 
 
 INDEX 
 
 Senile warts, flat, 208 
 Serous cysts, 672 
 Serpiginous lupus, 555 
 Serum eruptions, 477 
 Slough, 312 
 
 Smooth patches of tongue, 228 
 Soapy salves, 717 
 Soft chancre, 596 
 
 verrucose nevi, 666 
 
 warts, 666 
 Solutions, 714 
 Soor, 305 
 Sphacelus, 312 
 
 Spinocellular epithelioma, 676 
 Spirochete pallida, 610 
 Sporotrichium, 599 
 Sporotrichoses, 605 
 
 papillomatous, 249 
 Sporotrichotic gummas, 270 
 
 gummous lymphangitis, 270 
 Squamous eczema, 64, 72 
 
 erythema, 24 
 Staphylococci, 536 
 Staphylococcic impetigo, 167 
 Steatorrhea, 383 
 Stellate angioma, 695 
 Stimulants and rubefacients, 742 
 Stomatitis, diphtheroid, 305 
 
 impetiginous, 167 
 
 mercurial, 308 
 
 ulcero-membranous, 306 
 
 Vincent's, 306 
 Streptococci, 536 
 Streptococcic impetigo, 162 
 Strophulus, 45, 492 
 
 papules of, 141 
 Sudamina, 445 
 Sudoriparous abscesses, 446 
 Sulcated tongue, 226 
 Summer eruption, 185 
 
 prurigo, 498 
 Sunburn, 32 
 Sweat, 441 
 Sweats, colored, 444 
 Sycosis, 378 
 
 of beard, 379 
 
 on hairy scalp, 379 
 
 lupoid, of Brocq, 394 
 
 of mustache, 379 
 
 simplex, 378 
 
 treatment of, 380 
 
 trichophytica, 522 
 barbae, 380 
 Symmetrical keratoderma of adults, 
 
 212 
 Symptomatic infectious roseola, 25 
 Syphilides, 613 
 
 acneiform, 398 
 peripilar, 396 
 
 annular, 144 
 
 arciform, 144 
 
 bullous, 177, 620 
 
 Syphilides, corymbiform, 398 
 
 en bouquets, 398 
 
 erythemato-papular, 142 
 
 erythematous, 620 
 
 follicular, 396 
 
 granular, 396 
 
 herpetiform, 398 
 
 keratodermic, 619 
 
 lenticular, 129, 142, 619 
 
 lichenoid, 396 
 
 miliary, 396, 619 
 
 nigricantes, 143, 322 
 
 nodular, 271 
 
 nummular, 619 
 
 papular, 142, 619 
 
 papulo-circinate, 144 
 
 papulo-nummular, 144 
 
 papulo-squamous, 142 
 
 pigmentary, 326 
 
 psoriatiform, 216 
 
 seborrheal, 144 
 
 secondary, 619 
 
 of mucosa, 620 
 
 tertiary, 622 
 
 tubercular, 253 
 
 tuberculo-gummous, 285 
 
 tuberculo-ulcerative, 285 
 
 ulcerative, 284, 285, 620 
 
 varicelliform, 390 
 
 varioliform, 398 
 Syphilis, 610 
 
 acquired, 612 
 
 congenita tarda, 627 
 
 congenital, 624 
 
 precocious, 625 
 
 experimental, 612 
 
 insontium, 616 
 
 maligna precox, 284 
 
 pustules of, 172 
 
 treatment of, 632 
 
 ulcerations of, 284 
 Syphilitic alopecias, 411 
 
 bubo, 612 
 
 chancre, 613 
 
 of genital mucosa, 311 
 of mouth, 307 
 ulcerative, 283 
 
 ecthyma, 170 
 
 glossitis, 225 
 
 gummas, 267 
 
 of palatine velum, 268 
 of tongue, 268 
 
 leukomelanodermas, 332 
 
 onyxis, 436 
 
 patches, 144 
 
 pemphigus, 177 
 
 psoriasis, 216 
 
 roseola, 41 
 
 rupia, 170, 285 
 
 ulcerations, 285 
 Syphiloid, posterosive, 37 
 Syringocystadenoma, 673 
 
INDEX 
 
 767 
 
 Tattoo marks, 332 
 Teeth, Hutchinson's, 628 
 Tertiary phagedena, 295 
 
 syphilides, 622 
 Therapeutic notes, 711 
 
 radiodermatitides, 453 
 Thrush, 305 
 Ticks, 514 
 Tinea acuminatum, 424 
 
 crateriforme, 424 
 
 favosa, 420 
 
 imbricata, 528 
 
 microsporica, 421 
 
 tonsurans, 420 
 
 tricophytica, 424, 522 
 
 with large spores, 424 
 Tineas, 419 
 Tokelau, 528 
 Tongue, black, 229 
 hairy, 229 
 
 epithelioma of, 221 
 
 erosions of, 304 
 
 excoriation of, chronic superficial, 
 229 
 
 geographical, 228 
 
 leukoplakia of, 219 
 
 plaques of, depapillated, 304 
 
 red, 228 
 
 scrotal, 226 
 
 smooth patches of, 228 
 
 sulcated, 226 
 
 syphilitic gummas of, 268 
 
 villous, 229 
 Tophi of gout, 702 
 Toxic eruptions of internal origin, 472 
 
 pruritus, 484 
 
 purpura, 54 
 Toxicodermas, bullous, 177 
 
 papillomatous, 249 
 Toxidermas, 456 
 
 from internal causes, 471 
 Toxi-tuberculides, 565 
 Traumatic alopecias, 408 
 
 bull®, 175 
 
 eczema, 65 
 
 eczematiform dermatitides, 80 
 
 excoriations of genital mucosa, 310 
 
 gangrene, 313 
 
 onychoses, 432 
 Trench foot, 35 
 
 mouth, 306 
 Treponema pallidum, 610 
 Trichoma, 503 
 Trichomycoses, 428 
 Trichophytic folliculitides, 380 
 Trichophytine, 521 
 Trichophyton concentricum, 528 
 Trichophytons, 520 
 Trichophytosis, 519 
 
 disseminated lichenoid, 522 
 
 Trichophytosis of hairless skin, 522 
 
 palmar, 216 
 
 plantar, 216 
 
 of smooth skin, 114 
 Trichoptilosis, 418 
 Trichorrhexia nodosa, 417 
 Trichoses, 404 
 
 dystrophic, 416 
 
 parasitic, 419 
 Trichosporosis nodularis tropicalis, 428 
 Trichotillomania, 408 
 Trophedema of Meige, 371 
 Trophic ulcers of mouth, 308 
 Trophoneurosis facialis, 354 
 Tropical dermatoses, proliferating, 249 
 
 epidermomycoses, 114, 528 
 
 ulcers, 307 
 Tubercle, anatomical, 552 
 
 lupus, 553 
 Tubercles, 252 
 
 hypodermic, 252 
 
 of leprosy, 258 
 
 leprous, 587 
 
 lupoid, 259 
 
 lupus, 256 
 Tubercular leprosy, 583 
 
 syphilides, 253 
 
 ulcer, 288 
 
 fissured, 289 
 of genital mucosa, 311 
 papillomatous, 289 
 Tuberculides, 563 
 
 acneiform, 564 
 
 angiokeratotic, 564 
 
 eczematoid, 564 
 
 erythemato-atrophic, 564 
 
 erythematous, 564 
 
 erythrodermic, 564 
 
 follicular, 398 
 
 hypodermic, 564 
 
 lichenoid, 564 
 
 lupoid, 564 
 
 papulo-necrotic, 566 
 
 parapsoriatic, 564 
 
 pernio, 571 
 
 ulcerated, 291 
 Tuberculo-gummous syphilides, 285 
 Tuberculo-pustules, 160 
 i Tuberculo-ulcerative dermatoses, 253 
 
 syphilides, 285 
 Tuberculosis, 546 
 
 frambesiformis, 552 
 
 fungoid, 552 
 
 lymphangitic, 553 
 
 fungosa serpiginosa, 553 
 
 luposa, 553 
 
 miliary, of skin and mucous mem- 
 branes, 549 
 
 papillomatous, 247 
 
 pustules of, 172 
 
 ulcerations of, 288 
 
 vegetative, 552 
 
768 
 
 INDEX 
 
 Tuberculosis, verrucous, 247, 550 
 Tuberculous dermatitis, acute, 549 
 
 gummas, 268, 550 
 
 gummous lymphangitis, 209 
 
 lymphangitides, 553 
 
 melanodermas, 325 
 
 ulcer, 291, 549 
 Tuberous abscesses of axilla, 544 
 
 angiomas, 093 
 
 non-vascular nevi, 000 
 Tubular epithelioma, 079, 082 
 Tumors, calcareous, 092 
 
 connective-tissue, 089 
 
 epithelial, 009 
 
 vascular, 089 
 Tylosis, essential, 212 
 
 linguae, 219 
 Tylotic eczema, 72 
 Typhus, angiohematic, 57 
 
 Ulcer, rodent, 281, 082 
 
 tuberculous, 549 
 Ulcerated gummous infiltration, 288 
 
 herpes, 284 
 
 tuberculides, 290 
 Ulcerations, 277 
 
 acute, 281 
 
 of buccal mucosa, 304 
 
 chronic, 287 
 
 of dermatomycosis, 293 
 
 of genital mucosa, 310 
 
 of glanders, 293 
 
 groin, 251 
 
 of leprosy, 292 
 
 of leukoplakia, 307 
 
 lupus, 290 
 
 of mucous membrane, 281, 303 
 
 of phagedena, 293 
 
 sclero-gummous, 288 
 
 subacute, 284 
 
 syphilitic, 284, 285 
 gummous, 287 
 
 tuberculous, 288 
 Ulcerative chancre, 015 
 
 dermatoses, 281 
 
 granuloma of genital organs, 251 
 
 neoplasms of buccal cavity, 309 
 
 pemphigus, 187 
 
 syphilides, 020 
 
 secondary, 284 
 
 syphilitic chancre, 283 
 
 tertiary syphilides, 285 
 
 vegetative lupus, 555 
 Ulcero-membranous stomatitis, 300 
 Ulcers, 290 
 
 Annamite, 301 
 
 erosive, 070 
 
 of mouth, trophic, 308 
 
 Mozambique, 301 
 
 Ulcers, phagedenic, 281 
 
 of tropical countries, 301 
 
 simple, 290 
 
 tropical, 301 
 
 true, 281 
 
 varicose, of leg, 290 
 Ulcus cruris, 290 
 
 durum, 013 
 
 epitheliomatosum terebrans, 281 
 
 molle, 590 
 Ulerythema centrifugum, 509 
 
 ophryogenes, 402 
 
 sycosiforme, 394 
 Urticaria, 43 
 
 ab ingestis, 40 
 
 accidental, 45 
 
 acute, 45 
 
 autotoxic, 40 
 
 bullous, 45, 175 
 
 chronic, 45 
 
 factitious, 49 
 
 gangrenous, 317 
 
 giant, 49 
 
 hemorrhagic, 44 
 
 infectious, 40 
 
 papular, 45 
 
 perstans, 45 
 
 pigmented, 44 
 
 pigmentosa, 703 
 
 treatment of, 48 
 Urticarial erythema, 24 
 
 fever, 44 
 Urticarism, 43 
 
 Vacciniform dermatitis, infantile, 108 
 
 herpes, 108 
 Vagabond's disease, 329 
 Varicella, gangrenous, 171, 317 
 Varicelliform syphilides, 398 
 Varicose eczema, 73 
 
 nevi, 200 
 
 ulcer of leg, 290 
 Varicosities, lymphatic, 090 
 Varioliform syphilides, 398 
 Vascular nevi, 23, 093 
 
 tumors, 089 
 Vegetative tuberculosis, 552 
 Venereal warts, 238 
 Verruca necrogenica, 552 
 
 vulgaris, 240 
 Verrucose nevi, 000, 007 
 Verrocosities, 237 
 Verrucous elephantiasis, 240 
 
 excrescences, 237 
 
 tuberculosis, 247 
 Verruga Peruana, 593 
 Vesicles, 148 
 Vesico-pustules, 100 
 Vesicular dermatoses, 149 
 
INDEX 
 
 769 
 
 Vesicular eczema, 71 
 
 erythema, 24 
 Vespertilio, 571 
 Vibices, 52 
 Vincent's angina, 306 
 
 stomatitis, 306 
 Virginal pemphigus, 192 
 Vitiligo, 329 
 
 gravior, 582 
 Vulvar pruritus, 488 
 Vulvar leukoplakia, 220 
 
 W 
 
 War wounds, eczema of, 66, 73 
 Warts, common, 240. See Verruca 
 vulgaris. 
 
 flat, 127 
 
 juvenile 130, 241 
 senile, 208 
 
 plantar, 241 
 
 seborrheal, 208 
 
 soft, 666 
 
 venereal, 238 
 Watery pastes, 715 
 
 solutions, 714 
 Weeping eczema, 63 
 Wens, 671 
 Wheals, 43 
 White spot disease, 346 
 
 spots of smokers, 219 
 Whitlow, 163 
 Willan's lupus, 553 
 Wilson, leptothrix of, 428 
 Wilson's lichen, 131 
 Winter pruritus, 484 
 Woody phlegmon of aged, 544 
 
 Worn-off nails, 432 
 
 Wounds, war, eczema of, 66, 73 
 
 Wrists, eczema of, 75 
 
 Xanthelasma, 698 
 Xanthochromia, 697 
 Xantho-erythroderma perstans, 113 
 Xanthoma, 697 
 
 congenital, 699 
 
 diabetic, 699 
 
 eruptive, 698 
 
 glycosuric, 699 
 
 pigmentosum, 355 
 
 pilaris, 402 
 
 Yaws, 250, 646 
 
 Z 
 
 Zona, 154 
 
 buccal, 304 
 
 cervical, 156 
 
 chronic, 159 
 
 genito-crural, 156 
 
 hemorrhagic, 155 
 
 idiopathic, 158 
 
 intercostal, 156 
 
 lumbo-abdominal, 156 
 
 of mucous membrane, 157 
 
 ophthalmic, 156 
 
 peripheral, 156 
 
 recurrent, 159 
 Zoster fever, 156 
 
H 227 03 
 
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