THE PREVALENCE OF GERM DERMATOSES

BY

JAMES C. WHITE, M. D.Professor of Dermatology in Harvard University

Reprintedfrom the Boston Medical and Surgical Journalof January q, iBg6

bostonDAMRELL & UPHaM, Publishers

283 Washington Strest1896

THE PREVALENCE OF GERM DERMATOSES. 1

BY JAMES C. WHITE, M.D.,Professor ofDermatology in Harvard University.

When this Association was founded, scarcely twentyyears ago, the number of individual affections of theskin known to be caused by vegetable parasites wasvery small, some three or four only now the list ofthose, the origin of which has been positively de-termined to be of this nature, has increased to sixteenor more, and to these may be added six at least whichare in all probability of a similar character. Reckon-ing the number of diseases of the skin, as recognizedby this Society in its first published list, at one hundred,it appears that twenty or twenty-five per cent, of themare of vegetable parasitic origin. If in this categorywere also included all the forms of the more commondermatoses which have been in these latest days re-garded by certain observers as of this nature, aseczema, psoriasis, seborrhea, pemphigus, etc., thisproportion would be greatly magnified. Such claimswill, however, be disregarded in this paper.

I have thought that it might be not wholly withoutinterest to present to you a brief report upon therelative prevalence of this class of affections, as illus-trated by my clinic at the Massachusetts General Hos-pital during our last official year, in which 3,581 newpatients presented themselves for treatment. Theyrepresented several nationalities, twenty perhaps, andmany classes of society, including the educated andwell-to-do.

(1) Red sweat, one case.This condition is scarcely entitled to be called a

1 Bead before the American DermatologicalAssociation, September19, 1895.

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disease, although a cause of considerable annoyancerather from its visible effects upon the underclothingthan the appearances it produces upon the hairs of theaxillae. This bacterium, micrococcus prodigiosus, hasbeen said to grow more readily upon blond and red-haired persons. Perhaps more properly stated, it ismore easily discovered upon light-colored hairs. Itspresence may be regarded as a want of proper care ofthe axillae. It could scarcely develop upon personswho wash these parts with soap and water daily, butas favoring conditions for its growth may be said to bethe rule among dispensary classes and its occurrence isvery infrequent, but a single case presenting itselfduring the year, the germs must be proportionatelyrare with us. This bacterium is capable of very rapidgrowth, for the underclothing may be stained over aconsiderable extent, several inches in circumference,on parts in the neighborhood of the axillae after beingworn but three or four days.

(2) Erysipelas, 35 cases.The cases of erysipelas which find their way to the

skin clinic are generally mild forms affecting the face,where the traumatic origin is not apparent. No doubt,however, that slight abrasions of the cuticle or inappre-ciable solutions of continuity which accompany inflam-matory conditions of eyelids, nostrils, or ears, willaccount for the entrance of the Fehleisen streptococcus,and the frequent recurrent attacks of the affection inconnection with such chronic disorders of the facialorifices. I have frequently put a stop to a long seriesof recurrences of erysipelas by making the patient giveup the habit of continually picking the nose. Suchresults point to simple persistent or recurrent trauma-tism, and an omnipresent pervasion of germs as a suffi-cient explanation of recurrent erysipelas, and makethe theory of a persistent and attenuated germ virus,

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microhisme latent of the French, unnecessary. Thegrade of dermatitis in ordinary cases of this type rarelyexceeds the erythematous stage, and the active phaseof the parasite is brief, judged by the self-limited irri-tation it excites in any one area of the cutaneous tissues.Its vitality may be almost surely curtailed to a periodof two or three days, and the extension of the inflam-mation checked within the same period, by the applica-tion of mild parasiticides. I have continued to obtainsuch uniformly successful control over it by the methodalready described before this Association, namely, theconstant application of the following wash : carbolicacid, one drachm; alcohol and water, eight ounces ofeach. I have in several instances made a comparativetest of its action and that of ichthyol, so much used forthis purpose in some parts of Europe, by applying themsimultaneously to different parts of an affected area,and have invariably found the ichthyol far less effectivein controlling the extension and duration of the inflam-mation. I would again comment on the absence of allevidence of the contagiousness of such forms of ery-sipelas in the clinical history of my cases.

(3) Furunculosis, 59 cases.The majority of cases of furunculosis occurred in the

summer months among infants of the poorer classes asa sequel to heat-rash, eczema, and other forms ofdermatitis induced by heated rooms, foul clothing,lack of cleanliness and proper food, most favorableconditions to the admission of staphylococci to thecutaneous follicles, and to their rapid culture and ex-tension by auto-infection over large areas. In theother most frequent clinical variety the affection waslimited to some one and quite restricted locality, as theneck or one limb, where infection is conveyed fromone follicle to another in succession by the clothing orimproper use of poultices or other dressings.

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I feel assured that we may gain quite immediatecontrol of every case of furunculosis, however favor-able the soil for the development of the staphylococcusunder the influence of certain accompanying conditionsof the economy, by means of thorough asepsis of thecutaneous surface alone. This may be accomplishedby proper washing of the affected areas with a solutionof corrosive sublimate, one grain to one ounce, once ortwice a day, and by keeping the same constantlycovered with a cloth thickly spread with the followingointment: salicylic acid half a drachm, carbolated cos-moline one ounce.

(4) Carbunculus, no case.(5) Pustula maligna, no case.(6) Impetigo contagiosa, 91 cases; Ecthyma, 18

cases.Other very frequent forms of the condition well de-

scribed by the French school by the title “staphylo-coccia purulenta cutanea,” are the superficial derma-titis we call impetigo contagiosa, and the deeper-seatedinflammatory process, ecthyma. Although the lesionsof each are distinctively typical, and the diseases arewell defined in the main, yet we frequently meet withcases of extensive distribution where the two affectionsare intimately combined with each other and furuncu-losis, and in which it is impossible to state to which ofthem certain of the lesions should be ascribed. Theyare all caused by the presence of the pyogenic staphy-lococci, aureus and albus. Differences in the localityand the portion of the cutaneous tissues affected, inthe age, temperament, and general condition of thepatient will account in a measure, no doubt, for the di-versity in the character of the lesions excited by thepresence of these germs, but there must also be someas yet unrecognized specific quality in them by whichthe individuality of the respective affections is kept

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true, so that impetigo contagiosa, for example, almostinvariably reproduces its characteristic lesions uponany part of the surface of the same individual by au-to-inoculation, or when transferred to another child ofthe same family or a playmate. Its association in chil-dren with pediculosis capitis is so frequent that I neverfail to examine the hair in every case of impetigo con-tagiosa of the face or hands.

It scarcely needs mention that secondary forms ofpurulent processes, due to staphylococcia, are con-stantly observed in the course of many other derma-toses, but we must yet recognize the occurrence ofsome forms of pustulation and suppurative processesof the skin in which such germs are not found.

(7) Tinea trichophytina, 96 cases.Under this general title are included all cases of

ringworm of the general surface and hairy parts. Ifwe accept the conclusions of Sabouraud, with whichyou are acquainted, as put forth in his praiseworthyvolume, “Les Trichophyties Humaines,” recently pub-lished, they represent in all probability examples ofthree or more distinct affections, the individuality ofwhich has been established by differences in the micro-scopic appearances of the parasite found in them, inits seat, its longevity, and the results of cultureinoculation. He recognizes three principal forms :

First, trichophyton megalosporon (endothrix), theordinary benign form of the scalp and general surfacein children mostly, in which the plant presents certainbotanical varieties.

Second, trichophyton megalosporon (ectothrix),whichis always of animal origin. Two well-marked clinicalforms are recognized by Sabouraud : first, that derivedfrom the horse, which is highly pyogenic, producingagminate and circulate perifollicular purulent derma-titis, and the cause of the so-called kerion Celsi, and

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parasitic sycosis ; and second, that contracted from thecat, characterized by its more superficial and vesicularlesions. The results from culture of these two formsare quite distinct.

Third, trichophyton microsporon, in which the par-asite is not a true trichophyton, but is the small-sporedmicrosporon Audouini. This is the most common formof the disease in children, the most contagious and re-bellious, and the epidemics, which run through schoolsand asylums and last for many months or years, aresaid to be of this character. Its seat in the integu-ment is superficial, however, and it causes no perma-nent baldness.

It would be of great interest if these brilliant stud-ies of Sabouraud could be repeated by some competentworker amongst ourselves to determine if the results tobe obtained from material here are identical with his.

A noteworthy variety of parasitic dermatitis whichI have had frequent opportunity of observing in mem-bers of the “ crews,” “ teams,” and other athletes ofthe undergraduates of my university, affecting the cir-cum-genital regions, and differing from ordinary formsof eczema marginatum and erythrasma of these parts,and which is probably spread amongst them by thecareless interchange of clothing used in their sportsand towels, deserves mention here, and a proper bacte-riological study.

(8) Tinea favosa, 10 cases.These cases were all of immigrant origin, in Polish-

Russian Jews, or Italians. Favus is an extremely raredisease among the native New England population.Were it more contagious, the introduction of so manyimported opportunities into our common schools wouldcertainly make it more prevalent. A few instances ofpermanent alopecia, a sequel to favus, extinct in earlylife, were observed, as in other years, among the classes

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above-mentioned. On the polymorphism of achorionSchoenleinii I have no comments to offer.

(9) Tinea versicolor, 31 cases.They presented no noteworthy features.(10) Erythrasma, one case.But a single instance of this rare mycosis, caused by

microsporon minutissimmn, was observed, the first inseveral years. In my private practice it is of equallyrare occurrence.

(11) Tinea imbricata, no case.No case of Tokelau ringworm has ever been ob-

served in Boston within my knowledge. It is inter-esting to note that Sabouraud regards its parasite asbelonging to his class of trichophyton megalosporon.

(12) Actinomycosis, no case.(13) Mycetoma, no case.(14) Tuberculosis cutis, 22 cases.Under this single title all clinical forms have been

included, so-called lupus, scrofuloderma, verrucous andgummatous. In several instances two of them wereassociated, and in one patient all four coexisted. Theprobable history and source of infection in some ofthem was determined, one of which I have reportedto you in detail at this meeting. 2 In one or more ofthem tuberculosis pulmonum also existed, but it is notgenerally possible to determine whether the bacilli af-fect primarily the lung or skin tissue. Wheneverpracticable, I am convinced that the complete removalof all forms of cutaneous tuberculosis by excision isthe best method of cure. Every case of every kindshould be regarded as a serious menace to the life ofthe patient and to every member of the household.

(15) Lepra, two cases.One of the patients was a negro from the West In-

dies, the other was a Scandinavian girl. The latter2 An Etiological Puzzle, Boston Med. and Surg. Journal,December

5,1895.

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represented the second instance, which has occurred tome recently, of a difficult question, both in relation todiagnosis and one’s duty to society. Consider twogirls, recent immigrants from Norway, at service infamilies. Both of them present a chronic erythema-tous condition of the skin of considerable extent, andof no variable or ordinary type. It might well be aprodromal manifestation of leprosy, but there wereno other indications of that disease present that couldbe detected. Had they not been Scandinavians, orwere one not familiar with such possible early pro-dromal conditions, such a diagnosis would probably nothave occurred to a physician. Yet 1 saw in ProfessorBoeck’s wards for lepers in Christiania last year two pa-tients whose only symptoms were one or two erythe-matous areas of much smaller size. Possibly both mypatients would have been at once recognized as un-mistakable lepers by such an experienced observer.Now what was my duty ? These girls were depen-dent upon themselves for support. Should I informthe families in which they were living of my sus-picious, and cause their dismissal ? In this case theywould seek service and concealment in some otherhousehold, and thus pass out of professional observa-tion, Should I report them to the Board of Healthas lepers ? I could not do this, for no such positivediagnosis was possible, and without it I do not see howthey could have been sent back to their native country.We have no house of detention for observation, eitherState or National, unfortunately. The immediate con-dition of the girls was not dangerous to their associ-ates certainly. An examination of the affected areasfor bacilli was made in both cases, but the results werenegative. It proved nothing. The sensibility of theskin was unchanged. I decided to withhold my sus-picious, and to keep the cases under observation. I

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was not forgetful of similar early indications of my-cosis fungoides and sarcoma* One of the cases is be-ginning to exhibit a few suggestive tubercles withinthe erythematous areas.

I should be pleased to receive the counsel of mycolleagues here as to my duty in these cases, to thepatients, to the community, to the health authorities.They will recur to all of us.

Taken together, all the cases of these affectionswhich are to be regarded as of positively parasiticnature number three hundred and sixty-six, or rathermore than 10 per cent, of all the new cases presentingthemselves for treatment at the clinic throughout theyear.

In the second category, affections which are prob-ably caused by a vegetable parasite, the evidence ofwhich is, however, not yet positively established, maybe classed the syphilodermata, ulcus molle, some formsof alopecia areata, purpura and mycosis fungoides, of allof which instances in great or small number occurredduring the year, the total exceeding those of the firstclass.

It will be observed then that perhaps 25 per cent,of all cases of skin disease occurring in dispensarypractice are probably caused by vegetable parasites,and are, therefore, preventable affections. If to thesewere added all those produced by animal parasites,this proportion would be greatly magnified.

It seems to me that the importance of these factsshould be recognized not only by professional boardsof public health and school committees, but that someknowledge of them and of the proper precautionsagainst contagion should be disseminated among thepeople at large. And what a change have these dis-coveries brought with them in the making of the ac-

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complished dermatologist, in the teaching of our spec-ialty. Now, much more is necessary than the merelyclinical knowledge with some smattering of pathologi-cal histology, such as satisfied us older members of thisAssociation in our student days. Then, the size of theclinic, the readiness of the diagnostician, the skill ofthe practitioner, were the main qualities of the mostcelebrated schools of dermatology. Now, they are buta part only. The demands of the laboratory have be-come as great or greater than those of the clinic uponthe time of the student in our department in the bestschools of Europe. He must become thoroughlygrounded in the pathological anatomy of cutaneousdiseases, and I need not allude here to the diversity ofmorbid processes to which the skin is subject. Itknows them all. Nor is it longer possible to acquiresuch knowledge at the best under the teachers of gen-eral pathology. Fortunately there are those whosespecial acquaintance with the changes of the cutaneoustissues under disease has made their competency toteach them world-known. The requirements in sucha groundwork of dermatological study are well-nighinexhaustible. One of our most accomplished Euro-pean colleagues, whose contributions to this depart-ment of our specialty have been of great value, pointedto a seat in his private laboratory and said recently toa young student of dermatology, “There is your placefor the next two years.”

, But the bacteriological laboratory makes also a greatand necessary demand upon his time, if a requisiteknowledge of technique is to be acquired. Its appli-cation in this all-important field of inquiry in cutane-ous pathology cannot be over-estimated, and we maywell believe that the results of such studies are to beas brilliant for the progress of the therapeutics of der-matology as they have already been in etiology.

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It is evident that no school of dermatology can re-main great that relies upon its past clinical reputationand neglects the teaching of these most essential lab-oratory departments. Fortunately there is one schoolwhere all these branches may be studied in a completeway, and where general dermatology is taught in abroad and liberal spirit by eminent masters with un-equalled clinical facilities and a magnificent museum ofmodels. That constitutes a great school. Such isParis to-day, and there are other places where excel-lent laboratory instruction may also be obtained, byno means so well known to the student as they deserveto be, as Prag, Breslau, Lille and Bonn. Let us tryto make it not impossible before long to add someAmerican schools to the list.

S. J. PARKHILL i CO., PRINTERSBOS‘ON