general and local symptoms of a "reac-
tion," reliance must be placed entirely on
the induced fever.

(5) Cases apparently "recovered'' of-
ten react to tuberculin, thus proving
that there is tuberculosis, and that the dis-
ease is present in a latent form.

(6) The average time for the reaction
is 12 hours. The reaction, however, may
be delayed, some cases showing the char-
acteristic rise after 20 hours.

(7) Large initial doses for injection
should be used, as small doses tend to es-
tablish a tolerance, thus preventing a re-
action.

(8) Extreme care is essential when re-
action to tuberculin is suspected. The
preliminary temperature should be care-
fully, considered and all errors eliminated.

(9) Advanced cases of tuberculosis do
not, as a rule, react. If a reaction is se-
cured, it is generally obscured by prelim-
inary temperature oscillations.

(10) The use of the tuberculin test in
general practice is to be commended, if
the physicians remember the extreme
delicacy ;of the test, its linlitations. and
the necessity of the emplo)mient of a tlior-
ough and unvarying technique.

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527



PROPHYLAXIS AND TREATMENT OF THE COMMON
COMMUNICABLE SKIN DISEASES.*

H. R. VARNEY,
Detroit.



The object of this paper is to bring
about, if possible, a more perfect under-
standing of the subject matter among
the general profession in our section of
the country.

The diseases to be considered will be
only those contagious affections that do
not, as a rule, incapacitate the patients
by constitutional disturbances. They
are therefore attending school, or at
work, transmitting the diseases to all
who are susceptible to them.

The group of skin diseases common
to us all are impetigo contagiosa, scabies,
pediculosis, and ring-worm. These are
all caused by parasites, either animal or
vegetable, which grow in or upon the
skin, and are transmitted either directly
or indirectly from one person to another.
Much depends upon the susceptibility of
the person exposed.

Should children afflicted with any of
these diseases be allowed to attend
school, office, or factory?

For years past, in the public schools
of Detroit, there has been an unwritten
rule that teachers could send home a
child who manifested any symptoms of
skin affections, or uncleanliness. A note
explaining the temporary suspension was
sent to the mother. She, often ignorant
of the danger of contagion, does not con-
sult a physician and after she has done
what she can to improve the condition,

*Read before the Section on General Medi-
cine at the annual meeting of the Michigan State
Medical Society at Grand Rapids, May 27, 1904,
and approved for publication by the Committee
on Publication of the Council.



the child is sent back to school. The dan-
ger of contagion, however, is not re-
moved. This child may infect a large
percentage of the children in attendance
at that school, often causing a loss of
days or even weeks of the school year to
the delicate child who may suffer from
complications of these diseases.

Certainly in exercising the best pro-
phylactic measures, isolation of the pa-
tient is the first to be employed.

Since February, 1902, the Detroit
Board of Health, upon the suggestions of
its Health Officer, appointed a number of
physicians as medical inspectors in the
different schools. It is their duty to aid
in preventing the spread of ^11 contagious
diseases, by careful daily inspection of the
children in attendance. Statistics prove
how beneficial have been the results of
this system. For the school year, ending
1903, the number of pupils examined was
17,181; number excluded from school,
1,347. Of these, 198 were cases of pedi-
culosis; 59 impetigo; scabies and ring-
worm were classified with other diseases
so that the exact number cannot be ob-
tained. With that number of children
suffering from pediculosis, in daily at-
tendance at school and in over-crowded
rooms, there is great danger of contagion.
While with the average child, very little
inconvenience is experienced, yet there is
always great humiliation; and the deli-
cate child who is most susceptible to thwSe
diseases, may lose days or weeks of school
from the loathsome disease and its der-
matitises with glandular enlargements.

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Does this not offer argument con-
vincing enough to warrant the establish-
ment of such a system of inspection in
every graded school in our state?

How many physicians, general or spe-
cialists/ after making a diagnosis of
scabies, ring-worm, impetigo, or pedicu-
losis (for these diseases come to the no-
tice of us all) give instructions to either
patient . or parent in the prophylactic
measures to be taken until the child re-
covers? The child should remain away
from school, use his own towel, sleep
alone, and all his clothing, bedding, etc.,
be disinfected.

The exclusion from school of children
afflicted with these diseases is usually for
a short time only. It meets with the ap-
proval of the parents who are only too
glad to shield their children from the dis-
grace usually atendant on parasitic dis-
eases, and are glad to carry out promptly,
treatment prescribed.

Dr. Kiefer, Health Officer of Detroit,
told me that after, one of these medical
inspectors had been withdrawn from a
school, not only the principal and teachers
of the school, but parents of children at-
tending it, have requested his reinstate-
ment. This is the best proof of the bene-
fits derived from such a system. Not
only are these diseases discovered, and
the spread of them prevented in this way,
but many times mild, unsuspected cases
of the more serious diseases, such as scar-
let fever and diphtheria come under the
notice of the physicians and the precau-
tions necessary are taken and undoubt-
edly prevent any loss of time during the
school year, due to general disinfection.

These prophylactic measures in the
schools should exert a wide-spread influ-
ence, as they should tend to make the gen-
eral public more careful in all public



places, and with the use of articles com-
mon to the public, such as communion
cups, drinking cups, money, library
books, and all second hand material.

The importance of disinfection of
money and library books has been recently
shown by Dr. Darlington, of New York
City. During an experiment, he discov-
ered between 135,000 and 136,000 bac-
teria on one piece of paper money in ordi-
nary circulation. Staphylococci were
found on all bills examined.

As the treatment of these diseases is
so varied, the writer will deal with only
those recent, successful ones, which he
has been applying.

Impetigo contagiosa is not only a very
common disease, often epidemic, but it
is highly contagious among children.
While it is an acute inflammatory dis-
ease, due to the pus germs, it is self -lim-
ited, and responds readily to proper treat-
ment. The lesions are inoculable and
auto-inoculable, spreading rapidly; most
common with poorly fed and ill-cared for
children. After soaking off the charac-
teristic yellow crusts, a parasiticide in the
form of a mild, mercurial ointment as the
ammoniate, or yellow oxide, or sulphur
acts more effectively than lotions because
it not only protects the new skin, but pre-
vents in a measure, infection of other
areas. Absolute cleanliness is most im-
portant. Careful instructions should be
given to prevent infection of others, from
articles used by the patient.

Scabies or "itch" caused by the animal
parasite, Acarus-scabie, is another com-
mon, highly contagious affection. It at-
tacks people of all ages, and both sexes.
It is easily recognized by the general prac-
titioner by the most prominent symptom,
intolerant itching, and a history of other
cases similiarly affected, with whom the



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529



patient has come in contact. It is purely
a local disease and kx:al treatment that
will destroy the parasite is all that is
necessary. As a rule, all the patient re-
quires is proper instruction in carrying
out treatment for the irritation and dis-
comfort caused by the parasite at bedtime,
which is a sufficient reminder of anything
that will give relief. Before any medica-
tion is applied, the patient should take a
prolonged, hot bath, after which there
should be a thorough rubbing with a
coarse towel until the skin is well red-
dened. This removes all dead epithelial
cells and allows the medication to pene-
trate thoroughly. The most effectual
medication is sulphur in the form of an
ointment, U. S. P. This can be used
freely, without any general disturbance,
as a rule. This course of treatment car-
ried out thoroughly for three nights with
disinfection, baking or ironing of the bed
linen and underclothes worn by the pa-
tient will exterminate the cause of the
disease, although itching may continue
for weeks, with neurotic patients. Quan-
tities of flower of sulphur may be sprin-
kled between the sheets on the beds of
patients. This continues the medication
even during sleep. In skins with an idio-
syncrasy to sulphur, balsam of Peru and
naphthol may be substituted. Norman
Walker suggests that children that are
susceptible to a recurrence of this disease,
should wear small bags of sulphur about
the necks.

In the management and treatment of
pediculosis, I will consider only that
member of this parasitic family most
common in children; known as head-lice,
or pediculi capitas. This parasite is re-
sponsible for a large percentage of the
skin affections of the scalp, face, and body
of children, and it is my uniforni custom



and instruction in all dermatological af-
fections of the head to first look for pedi-
culosis no matter what the social rank of
the patient may be. This is easily accom-
plished by the presence of ova or nits on
the hair shaft. The patient may be kept
in ignorance of your search for these man-
ifestations of the disease. This loath-
some affection is easily recognized and a
cure may be assured if proper medica-
tions are aimed at the destruction of the
parasite. Close cutting of the hair of
male patients will facilitate all the treat-
ment. In my clinic practice, I prescribe
that the scalp be thoroughly soaked with
crude petroleum, .then bandaged for
twelve hours, after which a shampoo with
soap be given. This will, as a rule,
destroy not only the parasite, but the ova
on the hair shaft. Cider vinegar, full
strength may also be used with good re-
sults; both medications being household
articles, usually on hand. In private
practice, a shampoo of sulphur-naphthol
soap for several nights will be much more
acceptable, though perhaps not so effect-
ual, as petroleum. Infusions of staves-
acre or larkspur and quassia serve also as
good medications; and lotions of bi-
chloride.of mercury or carbolic acid if the
patient can apply them with care.

In the treatment of the varieties of
ring-worm, common among children,
much depends upon the location of the
lesions. Ring-worm of the non-hairy
portions of the body, responds easily
to local parasiticides. When there
is persistence or recurrence of the disease
it is due to some faulty constitutional con-
ditions, such as anaemia or scrofula. Yet
in the hairy portions of the body, such
as the scalp, an entirely different condi-
tion confronts us, as to treatment, because

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Jour. M. S. M. S.



the fungi are deep down in the hair shaft,
and medications do not so readily reach
the germs. More than three-fourths of
this affection occur under the age of
twenty, and are most common in children
of the school age. It attacks the scalps
of children because of the delicate resist-
ance of their skin to these fungi and
spreads because of the easy transmission
of the disease from one child to another
in their association at school or in insti-
tutions. Ring-worm of the scalp or body
should not be considered lightly by the
physician, for without proper precautions
many infections are sure to occur. As
the condition is often most obstinate, no
child should be allowed to attend school
or mingle with other children until the
disease has been pronounced cured, either
clinically or microscopically, and the
teacher notified to tiiat effect. In the
local treatment of ring-worm affecting
the hairy portions of the body, the great
numbers of remedies and combinations of
drugs given in our text-books demon-
strate the rebelliousness of this disease. I
feel that it is not so much the newer rem-
edies that are needed in the successful
treatment of this disease, as a skilful
application of one or two well tried, old
ones. The principles underlying the
treatment of ring-worm are first, to bring
in contact with the vegetable parasites, a
medication that will destroy them, without
harming the skin ; and second, to exclude
the air from the parasites, as it has been
proven that the parasite is aerobic and to
seal them means death. Therefore, a
medication that is a parasiticide and a
medium that will go down the hair-shaft,
and also shut out the air are the remedies
to be employed. Tincture of iodine and
mild preparations of mercury and resorcin,
^" collodion; and if the condition is rebel-



lious, chrysophanic acid or croton oil
may be resorted to. These medications
should be applied thoroughly and to do
so the hair should be cut, in order to re-
veal all the lesions. Epilations should be
tried if the condition is not too extensive.
This can be accomplished best after a few
days of treatment. Some protection of
the head, such as a skull cap of strong
paper should be worn by the patient, and
all articles such as wash ctoths, towels,
etc., used by him, be kept by themselves.
Disseminated ring-worm of the scalp
may last for months or years. Cases
have been reported, lasting nine years,
and many cases discharged as cured may
afterward come to all of us with a history
of previous treatment. Therefore, this
affection should demand the most prompt
and thorough treatment. Microscopic
examinations alone should determine the



cure.



DISCUSSION.



A. P. Biddle, Detroit.— That the child should
be excluded from the school when suffering
from an acute infectious disease there is no ques-
tion ; nor will there be much diflSculty in obtein-
ing the parents' assistance. But the difficulty lies
in the best means to be employed in exdoding
him from the school when the disease is chronic.
Take, for instance, a child suffering from the
ring- worm of the scalp due to the small- spored
fangus, a disease undoubtedly infectious, which
may exist not only for weeks but for months,
and in very rebellious cases even for years. It
is a very serious and difficult matter to exclude
the child from the benefits of public education.
The majority of these cases occur in the public
schools, and it is from the public school that
these children should theoretically be excluded,
but to exclude them from the school means to
drive them upon the streets and upon the street
they are almost as dangerous as in the school-
room.

Fortunately in the larger cities we have hospi-
tals devoted especially to the care of children
where, if necessary, they can be kept isolated
for months.

As to the disinfection of money, of public cups,
of the books of the public libraries, the difficulty

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53«



is not thut the lidvisability of disinfection is not
recognized, but that we have not yet brought
forward a method which is acceptable to the
public. We all recognize the value, but we have
not yet presented practical methods of disinfec-
tion.

Qvj L. Kiefer, Detroit. — I wish to endorse
the paper read by Dr. Vamey, and to add just
a few thoughts that occurred to me since the
paper has-been read. In regard to the methods
that we should pursue in order to bring about
the best results in these cases of skin disease, it
seems to me there are principally two. One is
that we should, as much as possible, get the co-
operation of the profession, and secondly, we
must get the co-operation of the laity. And there-
fore, I think that this paper, read at a meeting of
this kind, is very timely, because it will aid us in
getting the co-operation of both the profession
and the laiety.

There is one other point that I wish to bring
out, and that is that these skin diseases, their
appearance, their symptoms, and their treat-
ment should be discussed more than they are in
meetings of this kind. I fear that many of these
cases are not recognized. In fact I know that
they are not recognized by the practitioners in
large cities especially. During the last six weeks,
I think I can say that there were not less than
16 cases of scabies that have been considered sus-
picious by teachers in the public schools of De-
troit, sent home from schools in which there
were ro medical examiners. The cases had never
been treated; they do not go to physicians, that
is the reason we need to educate the laiety. One
of the cases I remember had been to a reputable
physician in our city, who told, the parents that
it was nothing at all, and that they had better
return the child to school, and thereupon it was
sent to me and found to be a case of scabies.
There were four cases in one family excluded
by the teacher; they went to at least four differ-
ent physicians and were diagnosed as nothing but
a rash that did not amount to anything. One of
them in particular was a very marked case of
scabies; so I say it is a good thing to bring
these discussions out at this time.

In regard to pediculosis, I went to see one of
the medical examiners of a school in Detroit
last fall when the children were being examined
for pediculosis and he found that out of 118 in
that school, 62 were suffering from that trouble.

In regard to disinfection of money and public
library books and various other matters of that
kind, Dr. Biddle told you about the difficulty of
bringing aboitt a uniform system in this respect.



but that is no argument against it, because we
know that nearly every sanitary reform will meet
with the opposition of the uneducated public.
And so if we are defeated, so to speak, in the
first attempt, we must try again, and accept the
suggestions thrown out by Dr. Varney, to bring
about some regular system of public disinfection
of these various articles.

In regard to drinking cups at fountains and
public places, the sanitary method would require
no cups at all. A short time ago in a conven-
tion of health officers that I attended, one case
was reported by a northern physician, in which
he traced syphilis to a child from a public drink-
ing fountain in that city. There was no ques-
tion but that, it came from that source.

Wm. F. Breakey, Ann Arbor. — I don't wish
to say anything except in a general way to com-
mend all that I have heard of the paper. I
should like to hear the subject well discussed.
A single point perhaps I failed to get, as to
the necessity (when the skin had been once
thoroughly disinfected) of the complete change
of clothing and every time that these disinfect-
ing applications are made. I think this is a prac-
tical point of much value. But we are not al-
ways able to provide against a reinfection or an
innoculation from clothing already infected. I
have found that to be the case often. That at-
tendants would be very particular in bathing the
patient, in puting on all the applications directed,
and then put on all the old ' infected clothing
again! The hour is so late I do not wish to
take more time. But I would like to take ad-
vantage of the opportunity to mention another
point I am especially interested in, and that is
the dangers arising from the communication of
skin diseases from the domestic animals. We
know that rats convey the plague, and cats carry
diphtheria, and dogs and sheep the mange, and
I think more often than we know of, skin affec-
tions of various kinds are communicated by
lower animals, and that wherever a case is found
(as when a case of typhoid fever breaks out, we
look about for the source of it), so when a case
of skin disease occurs of which the source is not
well known, I would suggest the looking around
at the domestic animals.

I am especially interested just now in get-
ting information on this subject, for I am pre-
paring a paper upon "Parasitic Sycoses Com-
municated from Cattle," and I will be very grate-
ful to any of my friends who will furnish me
with whatever information they may have on
this subject. I find that it opens a field not much
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532



DEFORMITIES OF THE FEET— NANCREDE.



Jour. M. S. M. S.



hitherto explored, in which there is an opportu-
nity to learn a great deal about diseases of the
skin.

H. R. Vamcy, Detroit— I will not take up
the time of the section further except to state
that Dr. Biddle's criticism is a timely one, and
will hold good in chronic cases.



It is rather hard to decide just what to do
with the chronic ring-worm. In many cases, es-
pecially of the scalp, I still feel justified in advis-
ing that they be kept home from school. In my
paper I mentioned the disinfection of the cloth-
ing as a very important factor in the treatment,
especially of scabies.



THE COMBINED USE OF PLASTER OF PARIS AND

ELASTIC TRACTION IN THE TREATMENT OF

DEFORMITIES OF THE FEET.*

CHARLES B. NANCREDE,
Ann Arbor.



Doubtless all my hearers are aware
that in the majority of cases of club-foot
treated with or without tenotomy, forci-
ble correction under anaesthesia with
maintenance of the improvement thus
secured by a plaster of Paris dressing is
a common practice, and that after allow-
ing the first dressing to remain for a num-
ber of days another redressment is usually
made, followed by a fresh plaster dressing
to hold the foot in its improved position.
These manoeuvers are repeated from time
to time, aided perhaps by anaesthesia and
mechanical devices to secure more power-
ful leverage until the foot is in a position
to wear a permanent brace or perhaps
only a walking shoe.

Many present have also seen all this
done with but slow progress or unsatis-
factory results, especially in adolescent or
older persons, and the position is taken
that of course in these latter classes of

♦Read before the Section on Surgery, Oph-
thalmology and Otology at the annual meeting
of the Michigan State Medical Society at Grand
Rapids, May 25, 1904, and approved for publica-
tion by the Committee on Publication of the
Council.



cases the osseous changes are such as to
negative success from simple measures,
which are only adapted to the partially
cartilaginous bones and readily yielding,
although contractured, soft parts of the
infant or young child.

Many orthopedists insist that division
of the neck of the astragulus, the removal
of this bone, or cuneiform tarsectomy is
both desirable and necessary in these older
patients. My desire is to show that re-
moval of bone is much less frequently
necessary than is often taught, and that
a better formed, more stable base of sup-
port can be secured without any mutilat-
ing operation.

All who have had experience with the
Phelps operation in adolescents or young
adults must have been impressed by the
wonderful amount of improvement
promptly effected by simple incision of the
soft parts without any division or removal
of bone, and also how little bone need be
removed when the pure Phelps operation
fails to secure all that is desired. Upon
the other hand most of us have seen what
improvement in the deformity has been

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DEFORMITIES OF THE FEET— NANCREDE.



533



affected in infants or young children, and
even in some adolescents, by elastic trac-
tion unaided by forcible manipulation and
often without tenotomy. As none of the
preceding contentions can be denied, it
should follow that an effectual combin-
ation of both must be at least superior
to one method alone. Continuous trac-
tion, exerting absorptive pressure on the
hard structures in the convexity of the
deformity and encouraging the natural
tendency of the soft structures to atrophy
when not kept elongated by traction, will
produce a more rapid change of form
than intermittent changes of the relations