CLINICAL LECTURE.

TINEA VERSICOLOR.

BY JOHN .V SHOEMAKER, M. D., LL. D.

Professor of Materia Medica, Therapeutics, Clinical Medicine and Diseases of the Skin, in the Medicochirurgical College and Hospital of Philadelphia.

GENTLEMEN-The patient before you is a young man, age 24 years; nativity, American, and barber by trade. There is not anything in his history of clinical import as regards his present disease of the skin, except the onset and its development. Four months ago his skin on the chest itched him more than usual, and on close inspection he noticed a number of small yellowish spots rapidly increased in size and coalesced, forming the large areas of yellowish colored skin, as you see it over his chest and back. These areas are irregular in shape and sharply defined, and covered with fine furfuraceous scales, which can readily be scraped off. In general, however, the color of the affected portions of the skin are of that peculiar fawn-colored cast that the French describe as "cafe au Lait," but it may vary from a pale yellow to brown, or even blackish color. The parts of the body usually affected are the chest and shoulders, although it also occurs on the neck, axilla, arms, abdomen, and back, but is very seldom on the face.

Diagnosis. The diagnosis of tinea versicolor is comparatively easy from its characteristic fawn-color usually present, the slight elevation of the affected skin and the furfuraceous desquamation. The furfuraceous desquamation especially should form the salient feature for diagnostic purposes, and if combined by the microscopic examination will leave little doubt as to the character of the disease. The diseases it might possibly be mistaken for are chloasma, vitiligo, lentigo, and macular syphilis; but on close examination and inquiry into the history will readily reveal the true nature of the affection.

Chloasma consists of a more or less diffused pigmentation of the mucous layer of the epidermis, while tinea versicolor is an affection of the horny layer. The patches of chloasma are smooth while those of tinea versicolor are elevated and furfuraceous, and the microscope will reveal the presence of the microsporan furfur in tinea versicolor. Lentigo are of the same nature as chloasma, differing from it only in their size. Vitiligo cannot well be confounded with tinea versicolor for the circumscribed areas in the former are white and colored in the latter. Syphilitic macules may prove perplexing, but the eruption is never so yellow as in tinea versicolor, nor is it elevated or does it desquamate. They are of a coppery hue, and an examination always develops a history of infection.

Pathology. The microscope shows that the lesions are largely composed of the spores and mycelium of the microsporon furfur. This parasite ramifies through the superficial layer of the corium, but does not penetrate the rete mucosum, nor does it attack the hair or nails. The mycelium is woven throughout the epidermic scales consisting of short, jointed and angular threads, which may be clear or contain spores. The spores are round, irregular or oval in shape, at times nucleated and are highly refractive. They may be developed from the mycelium or from pre-existing spores and manifest a tendency to aggregate in groups or clusters.

Etiology.-Tinea versicolor is caused solely by the presence and growth of the vegetable parasite on the skin, known as the microsporon furfur. The disease is contagious, but only in a mild degree. The manner in which the parasite reaches the skin is not exactly known, but it is supposed that it may be conveyed through the air, and in the water in which the patient bathed, or in which his clothes were washed. It attacks both sexes, the rich as well as the poor, the robust as well as the weak, and the cleanly as well as those who are careless in that respect. It is especially liable to attack the consumptives.

Treatment. The treatment is not quite as effective as pictured by most writers on this subject, but the disease can be entirely eradicated by persistent local application, though all evidence

of the parasite is gone. If you do not follow this plan your patient will be subject to relapse. It is well to prohibit the use of water to the affected areas, but the parts may be cleansed with a solution of tincture of green soap or a solution of sodii boratis, drams threre, in aqua hamamelidis destillatæ, fluid ounces five, The daily application of an ointment, which we will prescribe for this patient, consisting of

Small patches have been successfully treated with applications of tincture of iodine. Among other remedies, which may be employed, are beta-naphthol, boric acid, resorcin, phenal, or chry. saroline ointment. I have removed patches with daily applications of alcohol or boric acid dissolved in alcohol. When these lotions are applied it is well to use quite a good deal of friction to remove the furfuraceous scales.

Prognosis. The prognosis is good, though relapses are common if the parasite is not thoroughly eradicated.

Selected Articles

EARLY DIAGNOSIS AND TREATMENT OF PUERPERAL SEPTIC DISEASES.

BY S. MARX, M. D., NEW YORK.

It is indeed a sad commentary on the practice of modern midwifery, when your essayist of the evening, from the vast amount of gynecological and obstetrical material chooses as his theme so prosaic a subject as the early diagnosis and treatment of puerperal septic diseases. Yet, even though I could honestly state that these unfortunate complications were on the wane, the subject is one of interest to all whose duties bring them in contact with the woman to be confined, or one recently so. But far from this, my experience causes me to know that puerperal complications are not only not on the decline, but during the last few years on the increase. My actual incentive, therefore, is to call your attention to certain factors not alone from the prophylactic standpoint, but to those lesions which, from my experience, are curable when treatment is applied not alone early, but, what would be a better expression, timely. I approach the subject not in a captious spirit, but in one of altruism. Do not mistake the position which I take in this matter in which the "ergo" is more real than apparent. The issue which I want to present fairly and squarely is enunciated in the following sentence: "All puerperal septic complications are due to an infective area in some part of the genital tract. It can always be located by sight or touch. If attacked early and energetically the disease is readily curable, and will not lead to deeper and more dangerous complications. In short, early and active interference ought and will cure practically all cases of septic infections." In may seem foolish to you if I add provided we are dealing with a septic process at all, and this is another keynote to the situation. But more of this later. In the prophylaxis-and this has a strong bearing on

the subject-we have proven from original investigations personally conducted that the uterus is practically a sterile organ. Furthermore, a vast amount of scientific research has proven that the normal parturient woman possesses a vaginal secretion which has a decided inhibitory action upon pathogenic organisms. This secretion is markedly acid-its destructive action depends upon the lactic acid secreting bacillus of Doederlein. This can be determined by touch and sight. Clinically we have a vagina which requires no artificial preparation to enable us to conduct labor scientifically. The third portion of the genital tract, the vulva, is a different proposition in view of the fact that this territory contains bacteria that propagate actively, especially in the presence of air and in an alkiline medium. They are the Staphylococcus aureus and albus and the colon bacillus. Thus we are dealing with a part which is decidedly septic and infectious as is the ordinary skin, and must be treated as such according to wellknown surgical principles. Therefore in the management of an obstetric case from the modern standpoint we have but one area which must bear the brunt of our energies so as to render it sterile. This is the limitation of our preparatory treatment, so far as the normal woman is concerned. No antepartum douches, no vaginal toilet, etc., are permissible. So firm is my confidence in Nature's ability to destroy every possible pathogenic germ that may be introduced by operative or manual interference that, when the asepsis of the operator cannot be questioned, no uterine or vaginal douche is ever allowed either before, during, or after the operation. When from bacteriological experience or clinical demonstration this vaginal inhibitory action does not obtain, we are dealing with a secretion which is alkaline, profuse, maladorous and purulent, consequently pathological and in most cases gonorrheal. Now the indication is prophylaxis, and we anticipate the labor by appropriate treatment, and if, when labor sets in, the discharge is not normal, surgical scrubbings, such as are done prior to major vaginal work, are distinctly called for; and, if the labor be prolonged, vaginal douches are administered at short intervals with the hope of destroying, or at least inhibiting, the action of these pathogenic organisms. In approaching a normal