ABSTRACTS

VEGETATING DERMATITIS DEVELOPING DURING THE COURSE OF INFANTILE ECZEMA.

GROVER WENDE and HERMAN K. DEGROAT (Journal of Cutaneous and Genito-urinary Diseases, February, 1902) report two cases of a rare skin condition. The photograph represents the case when first seen, that of a patient about eight months old. The trouble began with seborrheal eczema, starting on the scalp when the child was only three weeks old, later spreading to the face. This process was active or quiescent at different times, like that of a typical eczema.

In December, 1896, the mother first noticed pustules on the scalp, which rapidly developed into quasi tumors. On January 30, 1897, when the case first came under their notice, lesions of the same character were found on the face and scalp. Most of them were nodular, squamous masses, varying in size from a bean to a child's fist. The larger were made up of smaller ones, which had coalesced and assumed an irregular contour. The lesions appeared rough and scaly and on removal of the débris a vegetating appearance was seen. Often in the border of the larger groups as well as in their immediate vicinity many small pustules appeared. These were found scattered over the whole involved surface, and varied in size and stage of development. They were sometimes found in groups but were usually isolated. After removing the scales, oleate of mercury was applied twice daily. The lesions cleared up in three weeks and did not return. No scarring resulted, and their only remaining trace was a slight pigmentation.

The second case was first seen March 8, 1901, that of a child then six months old, who was reported healthy at birth, nursed by her mother and continued well until she was five weeks old, when a seborrheal eczema was developed at the vertex of the scalp, which, in four months, spread over the entire scalp. When she was about four months old, and during an almost complete remission of the eczema, the lesions which were especially to interest us began to develop.. At first small and few in number they attacked the eczematous area, some appearing in groups while others were diffused. Others soon appeared, the older ones increasing in size, some becoming, in a very short time, as large as a walnut.

On examination, March 8th, the child then being six months old, the scalp still showed traces of the seborrheal eczema, but none was found on other portions of the body. On the scalp there were ten well developed lesions, varying in size from a pea to a hickorynut. These were well raised above the surrounding surface and were covered with crusts in which matted hair was embedded. On the forehead, near the median line, were two papillomatous lesions of filbert size, with uneven surfaces, covered with crusts, the entire mass being firm to the touch. The lesions

were well defined and the surrounding surface seemed healthy. On the right cheek, on a line with the nares, was a lesion surrounded by seven small discrete pustulo-papules, varying in size from a pinhead to a large pea. The small lesions contained very little pus at their apices, their bases were reddened and raised. On the left cheek was one large lesion the size of a 50-cent piece and 1 inch deep, composed of coalescent lesions; at two points a small amount of pus could be pressed out, and the most gentle manipulation resulted in bleeding. On the left leg, over the anterior surface of the tibia in its lower third, was an encrusted lesion about the size of a silver dollar. During the lapse of two weeks a number of minute isolated pustules appeared among those already formed. On the day following, in an effort to obtain bacteriological material, a crop of pustules appeared on the chest which showed upon examination three days later small isolated pustulo-papules extending over an area 3 inches wide by 5 inches long. There were about thirty of these lesions, from a

pinhead to dime size, raised above the surface, each one of them surmounted by miliary pustules. Three of them appeared papillomatous and formed circular reddish plaques.

As to treatment, as already intimated regarding the first patient, in six weeks all evidences of the disease were removed. In the second case, the treatment was simple; crusts were removed with water, having been previously softened with oil. Antiseptic ointments were applied, oleate of mercury was used on the head and sulphur upon the body. Both applications acted equally well. In eight weeks the condition had entirely disappeared, although the treatment was discontinued for two weeks in order to obtain material for bacteriological examination.

Bacteriological Examination.-Cover-slip preparations from the miliary pustules showed plenty of staphylococcus epidermidis albus. All kinds of media were used and inoculations from the pustules as well as teased tissue were made. The cultures after 24 hours showed white colonies which were almost a pure growth of diplococci, which were very small and were stained by Gram.

Further study, by the planting of microorganisms on the various culture media, potato, gelatine, milk, boullion, etc., showed almost a pure culture of the small organism which arranged itself singly, in pairs and in small bunches. A few of the tubes contained a mixed culture. Several colonies corresponded to those found in the previous tubes. The other organism was staphylococcus pyogenes albus.

FIG. 3.

Histopathology.-Two tumors representing different periods in growth were removed for microscopical examination. These were placed in Zenker's fluid and alcohol, and stained by various stains, including those for bacteria.

Horny layer. The horny layer was entirely removed or became moderately thickened. The surface contained much débris, consisting of blood corpuscles, shreds of horny epithelium, and, in portions not detached, large nucleated epithelial cells.

Stratum lucidum.-This was not discovered in the diseased skin. There were no cells to be found distinct from the stratum granulosum, although eleidin granules could be noted by means of the oil immersion.

Granular layer. The granular layer was deepened and, in the more recent growth, increased by two or three layers; it was, however, much thinner in the older lesions. There were a number of leucocytes seen in this as well as in the horny layer.

Rete. This layer was uniformly and excessively thickened, causing projections which dipped deeply into the cutis. Evidence of edema ap

peared. The superficial cells showed vesicular nuclei, although occasionally shriveled nuclei could be seen. All the cells, even the superficial ones, possessed distinct prickles, Leucocytes were found between the cells of the superficial layer and in certain places had resulted in a formation suggestive of pustules.

Cutis.-The blood and lymph vessels were specially dilated, particularly under the elongated papillæ. There was a decided infiltration of leucocytes and a few plasma cells in the papillary layer of the corium. In the deeper layer they were limited to close relation with the blood vessels. The leucocytes were almost invariably lymphocytes. Polymorphonuclear leucocytes were present, but rarely proliferating connective-tissue cells. In the older tissue the changes were essentially the same, although many of the cells showed regressive alterations, the leucocytes in many instances having aggregated and formed pustules. No microorganisms were discovered.

We find in each the following lesions: First, the superficial miliary pustules from which a droplet of pus can be squeezed. These are surrounded with reddened bases varying in size. As the base increases, the pustules apparently disappear. Later the lesion is covered with scales and crusts. At the same time the base becomes elevated above the surface of the surrounding skin and assumes a more or less circular papillomatous vegetating appearance, which is seen on removal of the crusts. These vegetations arise either from the base of a single pustule or by the coalescence of several lesions. They show a peripheral extension and form a group of pustules; the more recent ones, upon removing their crusts, appear intact at the border of the growth. The largest reach an elevation of I inch. The etiological factors are not striking. The first question is whether the dermatitis vegetans is strictly and entirely the result of eczema. This seems hardly possible, because such a complication is rarely manifested. May it not be due to a circumscribed or a secondary infection? Careful inquiry was made regarding other members of the family but no such cutaneous malady was found to exist. We know that non-specific lesions of the skin may accompany other forms of secondary infection. The mode of development and the rapidity with which the lesions responded to antiseptic treatment suggest the possibility of some microorganism as the inceptive influence in this affection. In differentiating these cases from those more recently specified in medical literature, one would naturally think of blastomycetic dermatitis, especially when the microscopical appearance is taken into consideration. The benign hypertrophy and the small accumulations of leucocytes suggestive of miliary abscess formations are points in common with that disease. No blastomycetes were found in the cutis by Dr. Gilchrist.

UNUSUALLY HIGH DEATH-RATE.

Although fewer cases of typhoid fever and of smallpox are reported to the Philadelphia Bureau of Health for the week ended February 15, the total number of deaths was unusually large-namely, 602, as compared with 581 for the preceding week and 522 for the corresponding week of