GENERAL DIAGNOSIS

It is needless to say that without the ability to make a diagnosis
in cutaneous diseases the management of the case in hand is haphazard,
unscientific, and culpable. Apparently it is the most difficult part of
the subject to the student and practitioner, and yet one in which the
seeming difficulties, if some careful thought and study, combined with
moderate clinical facilities for observation, be given to it, will, as regards
the commoner diseases—those with which the physician is most likely
to come in contact—soon disappear. Text-books cannot, however, take
the place of clinical opportunities, but with a relatively small amount
of the latter, and especially with the added advantage of good atlas
illustrations or cuts, book study is of great service in furthering and in­
creasing the knowledge thus gained. This presupposes, of course, a clear
idea of the characters and nature of the elementary and consecutive skin-
lesions—the a b c of dermatology. So much knowledge and training
possessed, subsequent errors are commonly due either to negligence or to
lack of thoroughness in the examination, or to the rarity or anomalous
character of the disease.

For diagnosis are required a good light, a good eye, and a good
microscope. The first two are essential; the last is in many instances
supplementary, but in some cases, as in determining the nature of
tumors and growths and in detecting the presence of parasites, it is
indispensable. In fact, its great value in studying pathologic proc­
esses cannot be too highly appreciated. In the examination of the
eruption gaslight is not satisfactory, as the color and other characters
of the efflorescences are obscured. He who would guard against error
must also insist upon seeing the whole or at least the greater part of the
eruption, for not infrequently the disease in a patch, area, or region may
be somewhat atypical or not wholly clear, and yet upon other parts be
so characteristic that all doubt vanishes. According to my observations
regarding students and practitioners, the failure to recognize the disease
most often hinges upon the laxity as to this point, and most of my own
earlier mistakes were likewise due to this cause. To avoid this pitfall,
therefore, a large portion, and in doubtful or obscure cases the whole erup­
tion, should be inspected. The word of the patient is not to be accepted
in lieu thereof, for this, especially when the eruption is on covered
parts, to save trouble or exposure or unintentionally from ignorance as
to the existence of other spots, areas, or patches, is frequently unreliable.
For example, the scalp may show a scaly eruption not always readily
differentiated from eczema or seborrhea, and yet bearing some sugges­
tion of psoriasis; if the latter, small spots or patches will almost surely
be on other parts, especially the extensor surface of the knees or elbows,
ill developed, perhaps, and yet their existence, even if of scarcely notice-

87

88

GENERAL DIAGNOSIS

able character, and probably wholly overlooked by the patient, will, in
almost all instances, be a conclusive factor in favor of psoriasis. Full
inspection discloses, moreover, the distribution, the color, evolution of
the lesions, tendency, if any, to patch formation, scaliness, etc The
temperature of the room should be that of a comfortable living-room, as
cold especially is apt to cause a confusing paleness or mottling, and some­
times materially changes the color of the lesions.

The distribution is of great importance from a diagnostic standpoint,
and especially when considered in connection with an associated factor,
such as sex, age, duration, and the presence or absence of subjective
symptoms or some other features. Pye-Smith¹ and, following him,
Hardaway² are, I believe, the only writers who have sufficiently em­
phasized this valuable factor in diagnosis, the former also using diagram­
matic drawings for this purpose.

Some regions are especially liable to certain affections, and free or
relatively so from many others, and this fact, known to its fullest extent,
will often immediately narrow the diagnostic possibilities down to a
comparatively small number of diseases, and the chance for error is
accordingly reduced; the differentiation can be then made by a con­
sideration of the other factors or features of the case. Duration is of
considerable import, and on this score inquiry can be made before in­
spection. History, though often valuable, is, as a rule, apt to be mis­
leading in many instances, except with patients of keen perception and
unusual intelligence, and, upon the whole, is best reserved for a supple­
ment to the objective examination. The character of the lesion is to be
noted, as determined by sight and touch, and its method of growth or
formation, whether erythematous, papular, vesicular, etc, and if uni­
formly so or mixed with other lesions; and whether there is any tendency
to special grouping or configuration, or any disposition to atrophy, ul-
ceration, and scarring. The presence or absence of itching—usually
disclosed, if intense in character, by excoriations—is sometimes a factor
of value.

Moreover, the age, social position, and environment of the patient
may occasionally be of some moment. For instance, in infants and
young children eczema of the face and scalp is quite frequent, and in­
flammatory disease of any duration in these parts can usually, therefore,
be set down as this affection. Lupus vulgaris and the scrofuloderm,
having its origin in the cervical glands usually present in childhood, and
miliaria, erythema intertrigo, and impetigo contagiosa are also most
common at this period. Acne is common to growing youth; sycosis and
trade eczemas—usually of the hands—to the active working period of life,
while in advancing years pruritus, eczema of the legs, face, and epi-
thelioma, and some of the other grave diseases, are more frequent.
Ringworm of the scalp, quite common in children, is a rare anomaly in the
adult, and may be considered as practically never occurring in the latter.
Parasitic diseases are, as is to be expected, more prevalent among the
lower and poorer classes. Syphilis is also more frequent among this

¹ Pye-Smith, Diseases of the Skin, 1893.

² Hardaway, Morrow’s System, vol. iii (Dermatology), p. 48.

DISTRIBUTION AS A DIAGNOSTIC FACTOR                89

class, and the late tubercular syphiloderm much more so, owing to the
less persistent treatment followed by this class of patients. Some diseases
are more common in the one or the other sex, and a few are practi­
cally limited to males, a few to females, but, upon the whole, this is of
but little value in diagnosis.

The value of a conspicuous feature or symptom, if present, in the
case is also very great, usually bringing the diagnosis within three or
four diseases, as in those cases where the malady is upon the scalp,
and of which a striking symptom is a patchy loss of hair; or in cases, say
on the face or elsewhere, where ulceration, or its result, scarring, is an
associated factor. With these preliminary remarks the diagnosis may
now be considered from several of the standpoints named.

DISTRIBUTION AS A DIAGNOSTIC FACTOR

Scalp.—In infants and young children the visibly inflammatory
(quite red, sometimes infiltrated) diseases commonly met with and in
which there is, as a rule, no hair loss and never patchy hair loss, are
eczema, dermatitis seborrhoica, impetigo contagiosa, and pediculosis;
non­inflammatory, or seemingly so—ordinary seborrhea, alopecia areata,
and some cases of pediculosis; slightly or moderately inflammatory,
sometimes scarcely visibly so, and with patchy hair loss—ringworm,
favus. In children of moderate age the same diseases, with the possi­
bility of psoriasis mildly to markedly inflammatory. Rarely, also,
boils, cutaneous abscesses, and syphilis might possibly be seen. In
youth and adults the same diseases as above except ringworm, and only
exceptionally impetigo contagiosa; but also frequently alopecia, ex­
ceptionally lupus erythematosus and epithelioma, and some rare dis­
eases. The most frequent diseases are eczema, dermatitis seborrhoica,
seborrhea, ringworm (except in youth and adults), alopecia areata,
psoriasis, and pediculosis (usually in dispensary practice).

Face.—In infants and young children eczema and impetigo con-
tagiosa are common, especially the former, and constitute the bulk
of the cases. Dermatitis seborrhoica, ringworm, miliaria, seborrhea,
herpes simplex, herpes zoster, and milium, furuncles, or cutaneous
abscesses occasionally; lupus vulgaris somewhat rarely; syphilis is
possible, and pigmentary and vascular nævi are not uncommon. In
older children about the same, but lupus vulgaris and other scrofulo-
dermata less rarely; freckles are common, erysipelas occasional, and rhus
poisoning is not infrequent. In youth and adults the same, but miliaria
practically never, except in connection with a generalized outbreak;
impetigo contagiosa relatively seldom, herpes simplex and ringworm less
frequently; but milium, seborrhea, dermatitis seborrhoica, syphilis, rhus
poisoning, and erysipelas are more common. Other diseases observed are
comedo, acne, acne rosacea frequently; epithelioma and lupus erythema-
tosus occasionally, and hydrocystoma rarely. In the bearded and
mustache region of the male adult, sycosis, alopecia areata, and ring­
worm (tinea sycosis), and in this region, as well as about the eyebrows
and nose, dermatitis seborrhoica is not uncommon. The brow is the

90

GENERAL DIAGNOSIS

common situation for chloasma, and also, usually, conjointly with the
scalp, for that rare disease, acne varioliformis. On the eyelids, xan-
thoma, and this and neighboring skin are the common seat of milium;
eczema about the edges, and also rarely pediculosis; at the inner canthus
epithelioma often originates. The eyebrows may also be the seat of
alopecia areata and rarely pediculosis. The nose and immediate neigh­
borhood are the usual site of acne rosacea, lupus erythematosus, and a
not uncommon situation for tubercular syphiloderm and lupus vulgaris,
epithelioma, seborrhea, and dermatitis seborrhoica, and the usual loca­
tion for the rare affection, adenoma sebaceum. At the edge and within
the nostril orifice, sycosis (folliculitis), impetigo contagiosa, herpes
simplex, eczema, and furuncles are not infrequent; lupus vulgaris,
syphilitic eruption or ulceration, and epithelioma, not infrequently
begin here, as well as rhinoscleroma, an exceedingly rare affection. The
lips are often the seat of eczema, herpes, and, especially at the angles,
syphilis, and the initial lesion is occasionally observed here; the lower
lip is a common site for epithelioma. On the ears, the most frequent
diseases seen are eczema, dermatitis seborrhoica, lupus erythematosus,
tubercular syphiloderm, lupus vulgaris, and epithelioma.

Psoriasis and other usually more or less generalized diseases are never
seen limited to the face, nor the rare diseases, lichen planus, pemphigus,
etc In countries where leprosy is not uncommon this region, especially
the brow, is frequently one of the first to show the disease. The most
frequent benign or practically non­destructive diseases upon the face
in youth and adults are eczema, acne, acne rosacea, seborrhea, derma­
titis seborrhoica, and, in our country, dermatitis from rhus plants.
The most frequent malignant or destructive diseases—characterized by
atrophy, ulceration, and scarring—are syphilis, lupus erythematosus,
epithelioma, and lupus vulgaris.

Neck.—In children intertrigo is common, usually anteriorly, and
eczema resulting from this or arising spontaneously is not infrequent;
occasionally ringworm is observed, and also scrofuloderm beginning
in the cervical glands just beneath the angle of the jaw. In growing
youth and adults eczema, acne lesions, ringworm, and, at the upper
(hairy) part, sycosis; impetigo contagiosa is also occasionally seen;
at the nape, furuncles are common, and carbuncles are not infrequent;
occasionally also herpes zoster extending up on to the face or down on the
shoulder and arm is observed.

Arms.—Eczema not uncommon; herpes zoster and tubercular
syphiloderm occasional. Extensor surfaces, especially at the elbow or
most marked at this region: Psoriasis, ichthyosis, and very exceptionally
xanthoma lesions; on the flexor aspects eczema, and exceptionally
xanthoma. Below the elbow, on the forearm, particularly the flexor
surface, lichen planus; and on the dorsal aspect, usually extending over
the hand also, the papular type of erythema multiforme. Ringworm
is not unusual in this situation. Eczema is quite commonly seated
conjointly on the lower forearms and hands. The arms frequently share
in other more or less generalized diseases.

Hands.—Dorsal surface, papules and rings of erythema multiforme,

DISTRIBUTION AS A DIAGNOSTIC FACTOR                91

usually extending part way up the forearm; and also lichen planus, ring­
worm, eczema, and very rarely lupus erythematosus, tuberculosis
verrucosa cutis, blastomycetic dermatitis; and occasionally tubercular
syphiloderm, and in those of advancing years, epithelioma. On the
palmar aspect eczema, pompholyx, callositas, keratosis palmaris, bullous
erythema multiforme; and syphiloderm, usually of squamous character.
Involving all the parts more or less, but generally especially pronounced
about the fingers and the interdigital surfaces—eczema, pompholyx, and
scabies, the last, however, only in association with the eruption else­
where. This region, alone or with the forearms, and sometimes the face
and other parts, is the seat of rhus poisoning and other forms of derma­
titis. The rare affections, dermatitis repens and erysipeloid, are also
usually seated here. The fingers alone are sometimes the seat of eczema,
pompholyx, and frost­bite. The dorsal surfaces of the hands and fore­
arms conjointly with the face are, as a rule, the seat of the bullous iodid
eruption. The dorsal surface, especially over the wrist, is the most
frequent seat of that rare condition, granuloma annulare.

Axilla.—Eczema, dermatitis seborrhoica, ringworm (eczema mar-
ginatum), and furuncles; the lesions of scabies are usually quite numer­
ous here, especially in the folds. This is also one of the usual sites
for the rare disease, erythrasma.

Chest.—Tinea versicolor, frequently extending down over the
lower part of the trunk, in the axillae, and occasionally in the groins
and flexures of the elbows and knees, and exceptionally on to the neck
and upward. The chest region, especially the sides, is also the starting-
place in pityriasis rosea. Anteriorly and posteriorly, one or both, espe­
cially in the sternal and interscapular regions—seborrhœa corporis,
dermatitis seborrhoica. Over the sternum, keloid; eczema, especially in
women about the nipple; and under the breast, frequently beginning as
intertrigo. Lesions of scabies are usual about the nipple in connection
with their presence in other regions. The mammary gland is, as known,
a common seat for carcinoma, and the areola and nipple for eczema and
Paget’s disease. Posteriorly, and over the shoulders, acne lesions are
common; and over the shoulders and upper part of the back the excoria­
tions and lesions of pediculosis corporis are usually most numerous.
The side of the thorax region is one of the most frequent sites for herpes
zoster, and an occasional one for the tubercular syphiloderm. The
upper part of the back is a not unusual site for carbuncle.

Abdominal Region.—This, as all other regions, may be the seat
of eczema, and the umbilicus is a favorite site; and this latter region,
as well as the lower part of the abdomen, commonly shares in the erup­
tion of scabies. Most of the cutaneous irritation in pediculosis pubis is
about the pubes and lower abdomen. The side of the abdominal region,
like that of the thorax, is not infrequently the seat of herpes zoster. The
trunk, as a whole, is the chief, and sometimes the sole, seat of pityriasis
rosea and tinea versicolor; and in common with other parts of the surface
usually shares in the general eruptive diseases, such as urticaria, lichen
planus, pityriasis rubra pilaris, syphilis, pruritus, erythema multiforme,
dermatitis herpetiformis, pemphigus, the exanthemata, etc

92

GENERAL DIAGNOSIS

Nates.—The eruption of congenital syphilis is often pronounced
here, and this region also usually shows an abundance of lesions in
scabies, especially at the anal cleft and in children. It is also a favorite
situation for furuncles; and in urticaria often exhibits the most pro­
nounced and the most itchy wheals. The anus is a frequent site for
eczema, pruritus, moist papules, and occasionally acuminated warts.

Genitocrural Region.—Erythema intertrigo, eczema, derma­
titis seborrhoica, pediculosis pubis, rhus poisoning, usually numerous
lesions in scabies, ringworm (eczema marginatum), and erythrasma.
The scrotum—a part of the genitocrural region—usually shares in the
eruptions just named, but may alone be the seat of diffused or follicular
eczema, pruritus, ringworm, furuncles, and elephantiasis. The same
can be said of the penis, on some part of which syphilis generally has its
starting-point, and on which also several or more lesions in scabies are to
be found; herpes simplex is usually limited to the glans and prepuce.
The vulva is likewise the seat of the same diseases as observed in the
male, pruritus and eczema being the usual ones; lupus vulgaris is also
exceptionally seen here, and also the rare affection kraurosis vulvæ.
Both the penis and vulva are occasionally the seat of epithelioma.

Leg.—On the upper part, or thigh, on its front and outer aspects,
keratosis pilaris; usually here alone, but occasionally conjointly with
it here, is also seen on the outer and posterior portions of the arms
and exceptionally elsewhere. On the same aspects of the thigh also the
lesions of pediculosis corporis are relatively numerous, while the inner
sides usually share predominantly in the scabies eruption. The thigh
is not uncommonly the seat of a sycosiform or follicular, sometimes
almost furuncular, eczema. The extensor surface of the whole leg
shows marked involvement in prurigo and ichthyosis, the latter more
especially well marked at the knee. This latter region is also, usually
conjointly with the elbows, and in most cases other parts, a common seat
for psoriasis lesions. The popliteal space is frequently alone or one of
several involved regions in eczema. Below the knee purpura lesions
are usually most numerous, with, as a rule, some but relatively less abun­
dant above the knee, and not infrequently upon the forearms, and occa­
sionally more or less generally. The tibial surface is the favorite one for
erythema nodosum, and the sides and posterior aspects for the rare
affection, erythema induratum. By far the most common, and, one might
readily say, the usual, disease of this region (lower part of the leg) is
eczema, frequently associated with varicose veins, and occasionally
originating in a dermatitis from the coloring-matter of the stockings.
It is also a frequent situation for that relatively infrequent disease,
lichen planus. Leg ulcers of all kinds, traumatic, varicose, and syphilitic,
are often seen here. The legs are also common locations for pruritus,
especially pruritus hiemalis and bath pruritus.

Foot.—Eczema, callositas, keratosis plantaris, pompholyx, the
last two usually on the soles alone, occasionally extending up over
the sides; in the latter region, also, hyperidrosis, with erythematous,
soggy edges. The toes and the interspaces are often the seat of eczema,
eczematoid ringworm, and likewise usually share in the scabies eruption.

DURATION AS A DIAGNOSTIC FACTOR

93

More or Less Generalized—Most common: Eczema, exan­
themata, psoriasis, urticaria, erythema multiforme, secondary syphilo-
dermata, pediculosis corporis, scabies, pruritus, medicinal eruptions.
Less frequent: Ichthyosis, miliaria, sudamen, dermatitis seborrhoica,
dermatitis herpetiformis, rhus poisoning, pityriasis rubra pilaris, lichen
planus, granuloma fungoides, multiple pigmented sarcoma, purpura,
scleroderma, xanthoma diabeticorum.

Universal.—Eczema, psoriasis, ichthyosis, erythema scarlatin-
oides, dermatitis exfoliativa, pityriasis rubra pilaris.

DURATION AS A DIAGNOSTIC FACTOR

Many cases of skin diseases are, as to duration, essentially chronic;
others are more or less acute. This fact can sometimes be utilized in
diagnosis, for very often when patients come under observation the
malady has already been of some days’ or weeks’ standing, and if so,
if no spontaneous tendency to natural defervescence has set in, the dis­
eases of short duration, which the one in hand may resemble, may
ordinarily be shut out in the diagnosis, unless the malady is evidently
kept up by a continuance of the causative factors, as is possible in ery­
thema intertrigo, miliaria, dermatitis medicamentosa, and some others.

To illustrate how this factor sometimes comes into play, take im­
petigo contagiosa and eczema, which sometimes present a close resem­
blance. Both are common in infants and young children, the former
more especially in the dispensary classes. If the duration has been more
than ten days or two weeks, and still with no apparent tendency to spon­
taneous subsidence, it is probably eczema; if of more than one or two
months’ duration, surely so. The same as to eczema and rhus poisoning,
the latter so common with us during our season of vegetation. Another
application of this fact is in the differentiation between psoriasis and the
secondary general papulosquamous syphiloderm; if the patient’s eruption
is more than of several months’ duration, the latter diagnosis becomes
less probable; if a year or more, absolutely excluded.

The short-duration eruptions, those scarcely exceeding several
weeks’ duration, and sometimes much less, are, it is true, relatively few,
but among these usually are: Acute circumscribed edema, dermatitis
medicamentosa, ecthyma, erysipelas, erythema intertrigo, erythema
simplex, erythema scarlatinoides, furuncle, herpes simplex, herpes
zoster, impetigo contagiosa, miliaria, urticaria, rhus poisoning, and
other cases of dermatitis due to temporary chemical, plant, or other
irritant; and frequently erythema multiforme, erythema nodosum, and
ringworm of the non-hairy surface.

The moderate-duration eruptions, scarcely exceeding one
or two months or by that time showing a spontaneous tendency to dis­
appearance, excluding those of variable and possible or probable chron-
icity, are: Dermatitis exfoliativa (some cases), erythema multiforme,
erythema nodosum, pityriasis rosea, pompholyx, purpura (some
exceptions), ringworm of the non-hairy surface, and most cases of the
secondary syphilodermata.

94

GENERAL DIAGNOSIS

TYPE OF ERUPTION AS A DIAGNOSTIC FACTOR

It is superfluous to say that it is unnecessary to consider eruptions
of a vesicular, pustular character, etc, in the diagnosis of a case in which
the rash is distinctly papular. The type of lesion is therefore often of
great service to the student, as well as to the practitioner, in bringing the
disease within reasonable proximity to a correct diagnosis. To a limited
extent this subject was touched upon in describing the lesions of the
skin, but an elaboration and a tabulation of the different more common
maladies upon this basis will prove of value. The size of the lesions,
region, and other characters and features calculated to be of some
additional aid will be parenthetically commented upon.

Erythematous eruptions may be: Common: Eczema (usu­
ally with slight scaling; about face if acute, sometimes simulating ery­
sipelas), erythema simplex, erythema intertrigo, erythema multiforme
(usually mixed with other forms), dermatitis (as from ivy, chemicals,
sun’s rays, etc), scarlet fever, measles, rötheln, erysipelas (usually
face, with considerable edematous swelling and sharply marginate
border, and constitutional disturbance), medicinal eruptions (especially
from copaiba, quinin, belladonna, chloral, opium, etc).
Rare: Erythema scarlatinoides.

Erythematopapular.—Common: Erythema multiforme (usu­
ally dorsal surface of forearm and hands), urticaria (more or less gen­
eral), insect-bites.

Rare: Dermatitis herpetiformis (occasionally or at times), measles
(occasionally), varicella (earliest stage), variola (earliest stage).

Papular.—Common: Eczema (small, usually aggregated or con­
fluent, and commonly regional; itchy), miliaria—prickly heat (small,
and usually in infants and young children; often itchy), keratosis
pilaris (small, discrete; thighs, outer aspects), erythema multiforme
—papular variety (large and usually backs of hands and forearms,
often crowded together; rarely itchy), milium (small, whitish, cystic,
discrete; commonly about eyelids), papular syphiloderm (general,
small or miliary variety, often with tendency to group; large variety
irregularly scattered; dark red or ham colored), acne (face, sometimes
shoulders; small or large, discrete, usually mixed with pustules), acne
rosacea (nose and immediate neighborhood, associated with passive
hyperemia and often capillary dilatation), sycosis vulgaris (bearded
region—male; associated generally with a predominance of pustules).

Occasional: Lichen planus (usually flat, dark colored, sometimes
slightly umbilicated; tendency to aggregation or confluence, with
scaliness; itchy), xanthoma palpebrarum (yellowish, soft, tend to form
confluent band), molluscum contagiosum (usually face, especially about
eyelids; pearly, translucent-looking, discrete, with central minute
depression and aperture), warts.

Rare: Pityriasis rubra pilaris (scaly, and tend to form solid scaly
sheets); prurigo, especially on extensors of legs, with board-like hard­
ness and thickening; itchy), lichen scrofulosus (usually on trunk, in one

TYPE OF ERUPTION AS A DIAGNOSTIC FACTOR          95

or several patches, as yellowish-red or yellowish-gray follicular papules,
closely crowded and slightly scaly).

Follicular papules are also usually seen in association with the milder
types of ichthyosis.

Papulosquamous.—Common: Psoriasis, eczema, keratosis pila-
ris. Not infrequent: Lichen planus, papulosquamous syphiloderm.
Rare: Pityriasis rubra pilaris, lichen scrofulosus.

Tubercular (Nodular).—Most common; Erythema multiforme
(dorsal surface of hands and forearms; rarely itchy), acne (face, some­
times shoulder and back also; associated with pustules and papules),
acne rosacea (nose and neighborhood, sometimes also cheeks, chin,
and middle of forehead; associated with hyperemia and capillary dila­
tation and commonly with pustules); tubercular syphiloderm (usually
limited area, with tendency to segmental configuration, and with pig­
mentation, atrophy, or ulceration), xanthoma palpebrarum (see under
Papular).

Infrequent: Lupus vulgaris (commonly about face, frequently the
nose, usually small or moderate-sized area, with disposition to group,
with tendency to ulceration and scar­formation; occasionally whole
region involved), molluscum contagiosum (see under Papular).

Rare: Xanthoma multiplex and xanthoma diabeticorum (general
distribution, but predominantly on the extremities; yellow). Epithe-
lioma often begins as a tubercle.

Vesicular.—Common: Eczema (regional, small, aggregated,
confluent, spontaneously rupturing; markedly inflammatory and itchy;
exceptionally, as on the fingers, discrete and somewhat firmer).

Not infrequent: Miliaria (as a rule, general, minute, numerous, and
crowded, but discrete, with but little tendency to spontaneous rupture;
inflammatory, usually itching, but of variable degree), herpes simplex
(usually large—except herpes progenitalis; regional, generally scanty,
and commonly on or near the lips; bunched or grouped, but little tend­
ency to spontaneous rupture), herpes zoster (regional, unilateral, large
lesions, and forming groups upon hyperemic or inflammatory skin, with
little tendency to rupture; frequently neuralgic pain and burning),
sudamen (general, especially trunk; minute, crowded, but discrete, clear,
translucent, and with little tendency to spontaneous rupture; not in­
flammatory; seen in association with systemic febrile diseases), varicella
(more or less general, most on trunk; discrete), scabies (about fingers
especially, associated with pustules, and with evidences of the eruption
on the other usual parts), rhus poisoning (small, large, discrete, and
crowded and confluent, often with considerable erythematous swelling;
most common about face, hands, and forearms, sometimes genitalia or
other parts, and generally quite itchy), impetigo contagiosa (usually
face or face and hands, after early stage becoming seropurulent, flatten­
ing, enlarging, and crusting).

Occasional: Erythema multiforme, urticaria (in both diseases an
accidental association with a predominance of the ordinary lesions).
Somewhat rare: Pompholyx (hands, feet, or both, especially palmar
and plantar regions; beginning deep seated; discrete and confluent,

96                                    GENERAL DIAGNOSIS

commonly going on to bullous development; inflammatory, and usually
of rapid development), dermatitis herpetiformis (more or less general,
with tendency toward small groups of three or four, and often associated
with bullous and erythematous lesions; inflammatory and usually
markedly itchy; chronic, with exacerbations), variola (early stage—
general, but most abundant on face and hands), hydrocystoma (face,
scattered, firm, shiny, translucent, with a bluish cast).

Rare: Hydroa vacciniforme (usually in boys, develops in early life,
is mostly on uncovered parts, and generally in summer, and leaves
variola-like scars; disappears toward adult age). Exceptionally vesicu­
lar eruptions may be medicinal in origin. Erysipelas may also show
vesiculation.

Bullous.—Erythema multiforme—erythema bullosum (an acci­
dental or anomalous development, usually about the hands, forearms,
and face, and frequently in association with the ordinary symptoms
of the malady), urticaria—urticaria bullosum (likewise an accidental
or anomalous development, and associated with the ordinary features
of the disease; the bullous lesions most commonly on the extremities),
impetigo contagiosa (in some cases several, and exceptionally all the
lesions, are distended and typical blebs; generally, however, in associa­
tion with other characteristic lesions), rhus poisoning (usually with
vesicles and considerable erythematous swelling; face, hands, and
forearms common sites, sometimes genitalia or other parts), dermatitis
herpetiformis (general, with tendency toward small groups of three or
four, usually with associated vesicles and erythematous lesions; as a
rule, markedly itchy, chronic, with exacerbations), pemphigus (general,
irregularly scattered, well distended, rounded, or oval blebs; occasionally
flaccid; often arising from sound skin, and often with systemic dis­
turbance—an extremely rare disease in this country), syphilis—bullous
syphiloderm (usually congenital, appearing at or just after birth, com­
monly most numerous about the palms and soles, becoming purulent,
and associated with other symptoms of the disease), medicinal eruptions
(exceptional; from iodids, and, as a rule, or predominantly, on the ex­
tremities and face; possibly also from other drugs).

Pustular.—Common: Acne (face, or with shoulders and back, or
exceptionally this last alone; discrete; associated with papules, come­
dones, and sometimes small, pit-like scars), eczema (most commonly
about scalp, and sometimes in association with pediculosis capitis; not
infrequently elsewhere, especially in connection with the hair-follicles,
as on face, thighs, and other regions; sometimes minute, crowded, and
rapidly forming crusts; in others discrete and larger; quite, itchy).

Not infrequent: Impetigo contagiosa (face, hands, and sometimes
elsewhere; developing from vesicles or vesicopustules, or originating as
pustules; if the latter, usually plump and rounded; tendency to coales­
cence and crusting; frequently associated with the ordinary vesicular
or vesicopustular lesions of this disease), bromid and iodid eruptions
(most abundant on the ordinary acne regions; rather bright pink or
red base, with, as a rule, relatively small pustular portion; exceptionally
much larger, and even the size of blebs; in the latter usually with papil-

TYPE OF ERUPTION AS A DIAGNOSTIC FACTOR           97

lomatous tendency), furuncle (commonly single, but sometimes several
in same region, always discrete, and most commonly at the back of the
neck; markedly inflammatory base, and painful and tender; sometimes
beginning deep seated, in others as a pustule at the hair-follicle), sycosis
vulgaris (bearded and mustache region, connected with hair-follicle;
discrete, crowded, and confluent; some lesions may be papular; inflam­
matory and chronic), tinea sycosis, or ringworm of the bearded region
(deep seated, nodular, or lumpy, furuncular, or pseudocarbuncular, and
usually some small surface pustules—see tumor eruptions following),
scabies (especially about the hands, where, as well as on the other
ordinary parts for this disease, other lesions are also seen associated),
pediculosis (occasional pustules not uncommon; in pediculosis capitis,
chiefly or wholly occipital; pediculosis corporis, most common across
shoulders and above buttocks; in pediculosis pubis, scattered over
pubic region), syphiloderm (generalized and secondary eruptions—
minute miliary, with tendency to group, and associated with minute
papules; in larger, acne-like, and varioliform eruptions—with no grouping
tendency, although usually numerous; in flat and large, or ecthymati-
form eruptions—rarely in numbers, but also scattered over surface, with
usually underlying ulceration; other symptoms present. In late syphilis
the papulotubercular or tubercular lesions, forming regional or limited
area or patch, may become pustular), variola (numerous and general,
but most abundant on face and backs of hands; usually umbilicated;
constitutional symptoms).

Infrequent: Ecthyma (large, flattened, markedly inflammatory
base and areola; usually on legs, and commonly in those of the vaga­
bond class; lesions rarely numerous). As is well known, vesicles often
become pustular.

Squamous.—Common: Eczema (usually one or several large
areas; regional; rarely extensive, and if so, frequently a history or pres­
ence of gummy oozing in one or two places; seated upon a thickened
red surface; good deal of infiltration, and rarely sharply defined; back
of neck, legs, face, and hands, common sites), psoriasis (sharply circum­
scribed, variously sized patches, usually general and scattered, with
preponderance toward the extensors, especially knees and elbows;
scaliness commonly abundant, and seated upon slightly elevated, red,
flat papules or patches, with but little infiltration; sometimes scales
have been rubbed off by clothing and perspiration; chronic and recurrent,
usually history of one or more years; exceptionally universal, and then
essentially similar to dermatitis exfoliativa).

Frequent: Papulosquamous syphiloderm (in general aspects, simi­
lar to psoriasis, but patches rarely larger than a silver quarter, with
no predilection for the extensor surfaces, less disposition to abundant
scaliness, seated upon dark-red, infiltrated papules or patches, with al­
ways some solid papules with no scaling tendency; relatively short history
and associated other symptoms of syphilis; may persist or appear as a late
manifestation in the palms and soles), seborrhea and dermatitis sebor-
rhoica (usually scalp, nose, and neighborhood, bearded region, or sternal
and interscapular region; greasy or unctuous characters; on scalp, com-

7

98

GENERAL DIAGNOSIS

monly diffused, with little, sometimes no, underlying redness; on nose
and neighborhood, usually thin, greasy scales or thin crusts, on pale or
hyperemic surface often showing sebaceous gland-duct involvement.
On sternal and interscapular regions, greasy scales or crusts, red base,
often segmental in arrangement, and often showing follicular dipping;
sometimes projecting and pseudopapular). Dermatitis seborrhoica
represents the cases in which there is underlying redness, with slight, but
variable, infiltration.

Less frequent: Lichen planus (usually regional and most frequently
on flexor surface of forearms and on the lower part of legs; when con­
fluent, form thick, scaly plaques, but, as a rule, at the edge or just beyond
it are discrete, flattened, often slightly umbilicated, dark-red, purplish,
or violaceous papules, with and without a minute scale; chronic and
usually markedly itchy; exceptionally more general), ringworm (scalp,
scaliness branny, and extremely slight; patch or patches usually rounded,
and some hair loss and hair stumps; on non-hairy surfaces ring-like
patch with clearing center, scaliness slight; slightly or moderately in­
flammatory edges; sharply defined and usually of short duration; on
crurogenital region, features of eczema, but sharply marginate).

Occasional: Ichthyosis (appears from first to third years, various
degrees: slight grade, usually noticeable only on extensors of the arms
and legs, especially about knees and elbows, and disappears in warm
weather. Moderately developed,—more marked on above situation,
and often arranged somewhat like squarish plates, frequently with some
follicular elevation, and also slight general scaliness,—disappears partly
or completely in summer; in extreme of winter may also show some scali-
ness about face, and likewise an eczematous tendency. Marked grade—
scaliness more or less general, most marked on extensors, where it con­
sists of thick plates; eczematous tendency or exposed parts in cold
weather; much better in warm weather, but does not disappear entirely.
Ordinarily, unless complicated by eczema, the malady is not inflamma­
tory). Favus (scalp usually, and in irregular patches or areas; yellowish,
mortar-like crusting, generally here and there saucer- or cup-shaped,
and the skin beneath usually red and atrophic; hair involvement and
loss), lupus erythematosus (usually face, and often on or near nose;
well-defined, red, elevated margin, with generally a tendency to in­
volution or atrophy in central part; scaliness slight and adherent, whitish
or grayish in color; gland-ducts usually perceptibly involved and often
patulous), pityriasis rosea (usually limited to trunk or extending to
thighs and upper arms, sometimes further; faint red, and often with
salmon tint; scaliness slight to moderate, and patches variously sized,
some or many with tendency to clear centrally; comes out within
several days or a week, and lasts from one to two months; as a rule,
not itchy).

Somewhat rare: Dermatitis exfoliativa (more or less universal);
scaliness slight or marked, and often exfoliated in large masses or sheets;
skin red, in some cases infiltrated, and in others often apparently thinned;
sometimes preceded and accompanied by constitutional disturbance;
lasts several months or indefinitely; usually recurrent; exceptionally

TYPE OF ERUPTION AS A DIAGNOSTIC FACTOR

99

fatal), lupus vulgaris (sometimes, instead of undergoing destruction,
lupus patches exfoliate,—lupus exfoliativus—the other characters being
as already described under Tubercular).

Rare: Pityriasis rubra pilaris (more or less general, but usually with
some places showing the beginning follicular papules; thickening and
variable scaliness, usually abundant, grayish, and quite hard. Ery­
thema scarlatinoides, scarlet fever, etc, present a thin, paper-like ex­
foliation or scaling; a slightly scaly condition is also not infrequently
seen with scleroderma, elephantiasis, and leprosy.

Multiform (Mixed—Two or More Lesional Forms).—Ec­
zema (any part or several regions; usually a predominance of one lesional
form; itchy), erythema multiforme (more or less general; commonly
papules and erythematous patches or rings, exceptionally with vesicles
and even blebs), dermatitis herpetiformis (general, commonly vesicles,
blebs, and erythematous patches; less frequently pustules also; usually
very itchy), acne (face, or face, shoulders, and back, or exceptionally
last alone; comedones, papules, and pustules), scabies (more or less
general, but usually worse on fingers, hand, wrists, axillary folds, geni-
talia, anal cleft, and feet; papules, vesicles, pustules, sometimes blebs,
and often “burrows”; very itchy), pediculosis (papules, often scanty,
small and large pustules, and excoriations; pediculosis corporis—general,
except face, head, and hands, but most marked over shoulders, about
waist, sacrum, and outside of thighs), sycosis vulgaris (papules and
pustules—bearded and mustache region), granuloma fungoides (usually
generalized, with eczematous-looking patches, nodules, and fungating
tumors).

Crusted.—Vesicular and pustular eczema, eczema rubrum, sebor-
rhea, dermatitis seborrhoica, favus (see under Squamous), impetigo
contagiosa, ecthyma, and sometimes the various other vesicular, pustular,
and bullous diseases.

Papillomatous.—Warts, syphilis, sycosis vulgaris, epithelioma,
tuberculosis verrucosa cutis, lupus vulgaris, blastomycetic dermatitis,
mycetoma, some bromid and iodid eruptions.

Atrophic or Cicatricial (Without Preceding Suppura­
tion or Ulceration).—The most common are favus (scalp), lupus
erythematosus (usually face and sometimes scalp), acne (some cases,
slight pitting).

Less frequent: Tubercular syphiloderm (some cases; atrophic thin­
ning, usually with pigmentation), lupus vulgaris (some cases; atrophic
thinning).

Rare: Morphea (usually one or several areas; on trunk, limbs,
or face), scleroderma (extensive distribution; extremities, trunk, and
face), folliculitis decalvans (scalp), glossy skin (fingers), maculae et
striæ atrophicæ (usually trunk or limbs), leprosy. Also acne varioli-
formis, in which the pustulation is sometimes scarcely noticeable.

Ulcerative.—Chiefly syphilis, epithelioma, lupus vulgaris, and
other varieties of tuberculosis cutis. Rare: Blastomycetic dermatitis,
mycetoma, actinomycosis, erythema induratum, leprosy; sometimes
ecthyma, sycosis vulgaris, tinea sycosis, acne, and, in rare instances,

100

GENERAL DIAGNOSIS

ingestion of iodids and other drugs, produce superficial destruction;
both furuncle and carbuncle may destroy a variable amount of tissue.
The ordinary leg ulcer, commonly varicose ulcer, is also a well-known
ulcerative lesion.

Tumor.—More or less generalized: Fibroma (variously sized
nodules and tumors, mostly sessile, with occasionally some pendulous),
granuloma fungoides (small and large tumors, and fungating growths,
commonly associated with erythematous, eczematous-looking areas),
sarcoma (usually melanotic and multiple pigmented varieties), mollus-
cum contagiosum (pearly-looking, usually sessile, with central punctum
and depression—extremely rare as a generalized eruption), leprosy.

Regional: Steatoma, gumma, molluscum contagiosum (usually
about face; see Tubercular), ringworm (chin and bearded region, espe­
cially under jaws, several or crowded, tumor-like, deep seated; frequently
discharging; exceptionally may consist of a single circumscribed nodular
mass, suggestive of carbuncle), erythema induratum (usually legs from
knees down, especially laterally and posteriorly; several or more, as a
rule; tendency to break down), keloid, and some others, both of regional
and general distribution.

Pigmentary and Pseudopigmentary (Discoloration).—
Common: Chloasma (usually about forehead, ill-defined, patchy, or
irregular areas; yellowish brown to brown; no textural change), freckles,
tinea versicolor (chiefly the trunk, and especially upper part, variously
sized yellowish or fawn-colored patches, areas, and sheets; often ex­
tremely slight branny desquamation noticeable; no other symptoms;
sometimes itchy when patient is warm), vitiligo (in whites, the brownish
pigmentation surrounding whitened vitiligo patches proper may in
some instances be much the more conspicuous feature; face and back of
hands favorite situations; no other symptoms). The various syphilo-
dermata (usually but temporary, although in some, as in the flat pustular,
it is, especially on the legs, often more or less lasting), nævus pigmentosus
(generally single; various kinds, from simply freckle-like spot to one
thickened, dark, and hairy), sebaceous wart (usually in the old, about
face, back, or hands; elevated, and generally covered with greasy, ad­
herent, thin crust), purpura (most commonly about legs; spots small
or large, red, changing to bluish, yellowish, and fading; hemorrhagic;
no textural changes), scurvy (dark reddish-brown to brownish-black
areas usually about the ankles), pediculosis corporis (if long continued,
with the consequent scratching, more or less pigmentation remains, often
well pronounced over the back and shoulders).

Rare: Lichen planus (frequently more or less permanent brownish
discoloration, especially when on the lower part of leg), chromidrosis
(especially about the eyes, where it is dark colored; also the axilla,
where it may be variously colored, often due to the presence of bacteria),
urticaria pigmentosa (more or less general; urticarial efflorescences leav­
ing sometimes yellowish, thin, xanthoma-like lesions, `but usually yellow­
ish to violaceous stains; begins in early life, and persists, as a rule, to late
youth), xeroderma pigmentosum (more or less general, freckle-like spots,
and telangiectases; later, with epitheliomatous growths; begins early in

A CONSPICUOUS FEATURE AS A DIAGNOSTIC FACTOR 101

life), acanthosis nigricans (more or less general, usually presenting features
of pigmented nevus, verruca, and ichthyosis).

Scleroderma has often associated with it a variable degree of brown­
ish pigmentation, and chronic, persistent eczema of the region of the
ankle is frequently followed by more or less permanent staining. Pig­
mentation is likewise observed in long-continued, markedly itchy
cases of dermatitis herpetiformis. It is also a not uncommon feature
of leprosy.

A CONSPICUOUS CHARACTER OR FEATURE AS A
DIAGNOSTIC FACTOR

In some instances many of the difficulties in the way of a diagnostic
conclusion can be surmounted by picking out a striking or somewhat
unusual symptom or combination, and, when possible, letting this be
the point from which the differentiation is approached. This is already
indicated in the consideration of the value of lesion type in the diagnosis.
Taking only the diseases with which the student or general practitioner
is likely to meet, omitting therefore the rare diseases, the value of this
method in many cases becomes in practice clearly evident, and few of
these points may be here profitably touched upon, even if necessitating
some repetition.

Patchy Hair Loss.—This, if present, even when but a single
area and not complete, is a striking and visible sign, and one that in
children usually brings the diagnosis within three diseases—ringworm,
alopecia, areata, and favus. It is true that a bald area might result
from a “blind boil” or cutaneous abscess, not uncommon with children
of the dispensary class; or from traumatism, or from some other de­
structive agent or disease, but the first and second are almost inva­
riably self-evident from inspection or history, and the others, rare.

In adults ringworm of the scalp is necessarily excluded, and the
diseases are narrowed to two, and if the case does not correspond to
the one or the other, then other rarer diseases in which this feature
occurs are to be considered—lupus erythematosus and folliculitis de-
calvans. Scar tissue, evidently resulting from previous ulceration, if
present, will also suggest syphilis. Patchy hair loss of the eyebrow is
sometimes an associated part of alopecia areata of the scalp, although
it may be the first sign of this disease. In the bearded region it generally
means the same, or tinea sycosis, or possibly sycosis vulgaris or lupus
erythematosus, or, if due to previous ulceration, syphilis or lupus vul-
garis.

Ulceration.—The diseases likely to be met with in which this,
or its result, scarring, is a feature, especially when on the face or other
region, excepting the lower part of the leg, are syphilis, epithelioma,
and lupus vulgaris; or occasionally other varieties of tuberculosis cutis;
syphilis—usually the tubercular or gummatous syphiloderm—being
responsible for the very large majority, lupus vulgaris being, in this
country especially, relatively rare. It is true boils, carbuncles, acne,

102

GENERAL DIAGNOSIS

and other diseases already alluded to (see under head of “Ulcerative”
Eruptions) may produce destruction and scarring, but these are acci­
dental, readily explainable, or a rare feature. The scarring of lupus ery-
thematosus is more of the nature of atrophy—no previous actual de­
struction, as commonly understood. On the lower part of the leg, in
addition to the several diseases named, it may be traumatic or a simple
ulcer, so often present here, and not infrequently associated with varicose
veins and eczema; and it may exceptionally be due to erythema induratum
or other rare affection. As a rule, ulceration of this region in those under
the age of thirty-five, if not traumatic or due to varicose veins, is almost
invariably of syphilitic origin; occasionally to lupus vulgaris, and ex­
ceptionally erythema induratum.

Ring-like Configuration.—Clearly cut annular patches or
rings, with partially or wholly normal central portion, are seen in ery­
thema multiforme (erythema annulare, erythema iris, herpes iris),
occasionally in some patches of psoriasis and the older patches of ring­
worm and pityriasis rosea (some patches); with partially clear or clear­
ing central portions—ringworm, psoriasis, syphilis, erythema multi-
forme (especially some of the older papules in the papular type), and
both secondary (more especially in the negro) and the late tubercular
syphiloderm, pityriasis rosea, dermatitis seborrhoica (more especially
on sternal and interscapular regions), impetigo contagiosa (rarely more
than one or two patches), and to a slightly developed extent in lupus
erythematosus. It is also usually seen as a part of the eruption in the
erythematous type of dermatitis herpetiformis, and occasionally in the
bullous form. Exceptionally it may also be observed in one or several of
the larger papules of lichen planus, in lupus vulgaris, and in some patches
in extensive general urticaria. On the face, when of short duration, it
usually signifies ringworm; syphilis or lupus erythematosus when of
considerable duration (the former frequently with ulceration); on the
hands or forearms, ringworm, erythema multiforme (recent, either per­
fect rings, as in erythema annulare, or merely with less pronounced fading
center, as in papular erythema), or tubercular syphiloderm; on the trunk,
possibly the last two, but about as probably dermatitis seborrhoica (cir­
cinate, segmental, and irregular, usually sternal or interscapular, with
greasy scales or crusts; recent or of long duration with fluctuations), pso­
riasis (in some or many patches, but not in all; clearing or clear center,
elevated, inflammatory, and scaly band-like border, occasionally fusing
and forming gyrate figures; eruption also elsewhere); or pityriasis rosea
(recent, slightly scaly spreading rings, clearing centrally, often fusing,
along with variously sized, slightly scaly macules). About the genito
crural region, usually ringworm. Granuloma annulare is a rare ring-like
or crescentic formation, most frequently seen on the dorsal surface of the
hand and about the wrist, sometimes elsewhere.

Segmental or Crescentic Grouping or Outline.—This may
be seen in the various maladies just referred to except lupus erythema-
tosus and lichen planus, and especially in ringworm and psoriasis as the
patches are finally disappearing; but most frequently points to the
tubercular syphiloderm (usually of long duration and often with ulcera-

A CONSPICUOUS FEATURE AS A DIAGNOSTIC FACTOR 103

tion), and to dermatitis seborrhoica (usually on trunk; occasionally on
scalp; exceptionally elsewhere).

Itching.—Generalized.—This immediately suggests the possible
generalized maladies, and the investigation most commonly leads to
a diagnosis among the diseases, urticaria, eczema, pruritus, scabies,
pediculosis corporis, sometimes psoriasis (itching cases). If such con­
clusion is impossible after examination, then other diseases, such as
lichen planus, miliaria, some medicinal eruptions, and the rarer affec­
tions in which this symptom is usually a factor can be taken up. The
syphilodermata do not itch; to this statement, however, exception must
be noted as to the negro, who often complains of pruritus in connection
with these eruptions, especially with the miliary papular and pustular
manifestations.

Localized itching as a symptom in regional eruptions is also of some
value, the most common maladies thus characterized being eczema,
pruritus, pediculosis capitis, pediculosis pubis, seborrhea, and derma­,
titis seborrhoica (often absent), lichen planus, urticaria of limited dis­
tribution (uncommon; the eruption usually general), regional miliaria,
rhus poisoning, and other forms of dermatitis venenata, etc., and also
in some of the less frequent maladies. Pompholyx (hands, feet, or
both) in some cases is quite itchy, but, as a rule, the subjective symptoms
are more frequently or predominantly those of burning and soreness.

Color.—This has already been partly considered under the sub­
heading of “pigmentary and pseudopigmentary” in discussing the
lesional types of eruption. The yellowish or fawn color of tinea versi-
color; the brownish of chloasma; the bright red, not disappearing upon
pressure, and changing through several shades to yellowish, of purpura,
the yellowish to black of the freckle, pigmentary nevus, etc.—all are of
value in leading to a correct diagnosis. The character of the color—
the brightness or deepness of the red in inflammatory and other dis­
eases—is sometimes of at least corroborative aid in limited or general
eruptions, whether erythematous, papular, or other type. The brilliant
red of scarlet fever and the usually deeper brilliant red of erythema
scarlatinoides are much alike, but the shade of difference sometimes
exists and is recognized by the practised eye. The brighter, more in­
flammatory tint of eczema, psoriasis, etc., as compared to the sluggish
red, coppery, or ham tint of the syphilodermata, may also sometimes
be utilized. The usually slight yellowish cast mellowing the red of
lupus vulgaris frequently may be used as one point of difference from
the copper or ham tint of the red of the tubercular syphiloderm. The
yellowish tinge very commonly present in dermatitis seborrhoica is, as a
rule, not observed in ordinary eczema. The deep red, with violaceous
tint, or distinctly purplish papules of lichen planus, is different from
other papular manifestations. The yellow color of the tubercles of
continuous band about the eyelid is characteristic of xanthoma, and
also of the more generalized eruption exceptionally seen in this disease and
xanthoma diabeticorum. The yellow color of the friable crust-masses
of favus is also usually helpful, sometimes distinctive.

The value of these positive differences in color is recognizable both

104

GENERAL DIAGNOSIS

by the general physician as readily as by the expert, but for the finer
differences of shade some training and experience are necessary.

Odor.—This is occasionally of some value, as the mousy odor of
favus, the characteristic fetid odor of small­pox, the often offensive
smell of the ulcerative syphilitic lesions, while that of bromidrosis is
peculiarly penetrating and disagreeable, and that of gangrene usually
characteristic, as also the nauseating odor of the condition sometimes
brought about in pediculosis capitis. It is subject, however, to so
much modification, lessening, or intensification, or covered up by other
or worse smells, due to the habits and environment of the patient, that,
except as a corroborative factor, it is not very reliable.

But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy!

Also, please consider sharing our helpful website with your online friends.