ERUPTIVE OR MILD FORM 



1573 



eruption shows itself at first as small, pinkish -red, erythematous 

 spots, sometimes associated with small vesicles, or more rarely 

 with bullae or pustules. The erythematous areas speedily become 

 papules, and finally nodules, which may vary in size and in number. 

 The usual size is about that of a pea. 



When fully developed, they appear as elevated, cylindrical, fungi- 

 form, or irregular wart-like bodies, usually discrete, red in colour, 

 generally firm to the touch (though they may be soft), and very 

 liable to bleed. This type of eruption is the forme miliare (miliary 

 type) of the Odriozolas and Salazar. In addition to these super- 

 ficial tubercles there are deep subcutaneous nodules (nodular type), 

 which lie under the unaltered skin, and from which at first they are 

 quite free. These nodules may reach a large size, and become 

 adherent to the skin, ulcerate, and reach the surface as large red 

 f ungating masses, which readily bleed. This is the forme midair e 

 of the above-mentioned authors. Both types appear on the skin, 

 but the miliary type may also appear on the mucous membranes 

 and internal organs, while the nodular type is confined to the skin, 

 especially at the flexures of the elbows and knees. The first crop 

 usually appears on the face, and the extremities may be discrete or 

 confluent; in the latter case no healthy area of skin may be visible. 

 The miliary eruption may appear when the general symptoms have 

 abated, but the nodular is accompanied by fever. 



The area of the skin on which the spots appear is usually 

 oedematous, a feature most commonly observed on the legs. With 

 the appearance of the eruption the fever declines, the general 

 symptoms abate, and the patient feels better, but the blood shows 

 a marked diminution in the red cells, some of which are nucleated, 

 and a corresponding reduction in the haemoglobin, and this anaemia 

 may be aggravated by haemorrhages from the nodules, which may 

 be so severe as to cause the death of the patient. This blood 

 condition has been carefully investigated by Monge, who finds that 

 at the commencement of the illness there is oligocythaemia, micro- 

 cytes, macrocytes, normoblasts, and megaloblasts (under 1,000 per 

 cubic millimetre), with poikilocytosis, polychromatophifia, and 

 granular red cells. The haemoglobin value is raised. The white 

 cells are increased, and there is slight polymorphonucleosis. The 

 mononuclears have well-marked basophilic protoplasm. At this 

 stage the verrugas may develop in the internal organs, and cause 

 serious symptoms; thus in the larynx they will cause dyspnoea; in 

 the bronchi, bronchitis; in the lungs, pneumonia; in the pleura, 

 pleurisy; in the nose, epistaxis and difficulty in nasal breathing; 

 in the oesophagus, dysphagia; in the intestine, bloody diarrhoea; in 

 the meninges, brain symptoms; in the eye, amblyopia; and in the 

 uterus, metrorrhagia. 



After lasting from four to six months, during which several crops 

 appear and disappear, each preceded by an attack of fever, the 

 eruption finally disappears, and the nodules, becoming pale and 

 drying up, disappear without producing a scar, while the ulcerated 

 nodules dry up and heal bv cicatrization, and the patient is left 



