MOLLUSCUM CONTAGIOSUM

Synonyms.—Molluscum epitheliale; Molluscum sebaceum; Epithelioma mollus-
cum; Epithelioma contagiosum; Acné varioliforme (Bazin).

Definition.—A contagious disease of the skin characterized by
pin-head­ to pea-sized or larger, rounded, semiglobular or slightly flat­
tened, pearl-like elevations, of whitish or pinkish color, and with minute
central depression.

Symptoms.—The lesions begin as pin-head-sized, waxy-looking,
rounded or acuminated elevations, which often, in the very beginning,
bear some resemblance to minute warts. They gradually attain the
size of pin-heads and small and large peas, and display, sometimes
quite perceptibly, in others visible only on close inspection, a depression
or umbilication, in the center of which is noted a darkish point repre­
senting the mouth of the follicle. In the beginning they are usually
rounded or semiglobular; as they increase in size the top becomes some­
what flattened. They have a broad base, but occasionally in some cases
in a few lesions, after some duration, a tendency to become pedunculated
is noted. They may be either whitish, almost skin colored or pinkish,
and often look not unlike drops of wax or small pearl buttons. Some­
times they have a slight resemblance to the prepustular lesion of variola;
hence the French term, acné varioliforme (Bazin). While firm at first,
and sometimes continuing so, they usually, as they increase in size, tend
to soften slightly, and if squeezed emit from the central orifice a semi-
solid, cheesy-looking substance. Sometimes this latter, slightly or
moderately hardened, projects a line or two out of the opening. Some
lesions, after weeks or months, having attained the size of a moderately
large pea or small cherry, redden, become inflamed, tend to break down

646                                        NEW GROWTHS

and suppurate, and then heal up and disappear, usually without trace.
As a rule, however, they are sluggish in character and unaccompanied by
any active signs of inflammation. Not infrequently, indeed, the lesions
disappear slowly by absorption, and possibly partly by desiccation,
without apparent previous softening. The course of a single lesion
varies, sometimes disappearing spontaneously in several weeks or a few
months, or lasting one or two years. As a rule, while the older ones
are gradually disappearing new growths may present, so that, if at
all numerous, all sizes and various stages are commonly to be seen.
Inmost cases 10 or 12 lesions are present, although occasionally they
may be quite numerous.¹ They are usually discrete, but exceptionally
2 or 3 may be bunched together,² and in rare instances are somewhat
closely packed, forming almost a solid mass.³ Their most common

Fig 151.—Molluscum contagiosum.

seat is the face, but not infrequently, along with those on the face or
independently, the growth occurs on other parts,⁴ more especially such

¹ Frick, Jour. Amer. Med. Assoc, 1899, i, p. 536, reported a case, a male adult,
with over 400 lesions, chiefly about face, neck, forehead, and scalp; and also cites other
instances, with references. In a recent institution (for young men) epidemic observed
by Hartzell, not only were the lesions numerous, but almost all small, and in all cases
on the trunk and arms; three cases from the same epidemic came under my care, each
with about 100 lesions, also all small, and all on trunk.

² Crocker, Diseases of the Skin, third edit., p. 730, describes a case in which there
were compound tumors with 2 or 3 openings or plugs.

³ Hallopeau, Jour. mal. cutan., 1899, P. 405, records a remarkable case in a woman
presenting numerous and variously situated lesions, in some places closely crowded
together and resembling bunches of grapes.

⁴ In Fordyce‘s case (Jour. Cutan. Dis., 1892, pp. 367 and 372) the lesions were on
inner aspects of both thighs, just above the knees; Pringle‘s (Brit. Jour. Derm., 1898,
p. 198), on the scrotum, perineum, and contiguous parts, and in another (ibid., p. 418)
on the scalp; Abraham‘s (ibid., 1899, p. 474, in addition to a large number of wide dis­
tribution on the cutaneous surface, the mouth was also the seat of lesions, closely
crowded together, resembling plaques of leukoplakia, and there were also massed
lesions on the penis; Allen‘s (Jour. Cutan. Dis., 1886, p. 238), some lesions on the ver­
milion border of the lips; Sprecher (Dermatol. Centralbl., Sept., 1899, p. 354), on the
dorsum of one foot.

MOLLUSCUM CONTAGIOSUM

647

as the neck, breast, arms, scalp, and genitalia. In the last region they
seem more common on the Continent of Europe than in England or in
our own country. In rare instances the eruption has been more or less
generalized, sparsely scattered, or numerous. On the face, the most
common situation is about or on the eyelids, and even on the border,
in this latter situation sometimes exciting considerable irritation, and
exceptionally a conjunctivitis (Steffen, Muetze).¹ While in almost all
cases the size of the lesion may vary between pin­point and an average
pea in size, occasionally they are somewhat larger, and very exceptionally
they may attain much greater dimensions, rarely, however, the extreme
size (molluscum giganteum), of one to several inches in diameter, as
in cases described by W. Smith,² Laache,³ Kaposi,⁴ and a few others.

There are no subjective symptoms, the lesions appearing and con­
tinuing throughout their course, with apparently no pain, itching, or
burning. Those which become inflammatory accidentally or spon­
taneously by tendency to break down may be slightly sore and painful.
There are no constitutional symptoms.

Etiology.—The disease is contagious. Since the time of Bate-
man, who first clearly described the malady, there has been much dis­
pute on this point, but in England,⁵ where it is apparently more common
than elsewhere, its contagiousness has been generally recognized; and
this is supported in this country by the overwhelming evidence presented
by Fox, Allen, Mittendorf, Jackson, Graham, Knowles, myself, and others.⁶
Wigglesworth, Allen, and Brocq were subjects of accidental inoculation,
Retzius, Peterson, Vidal, Stanziale, Pick, Haab, and Nobel succeeded
in experimentally producing the disease; there are, it is true, many

¹ Steffen, Klin. Monatsblatter f. Augenheilkunde, 1895, p. 457, and 1896, p. 66;
Muetze, “Ueber Molluscum Contagiosum der Lider,” Archiv f. Augenheilkunde, 1896,
vol. xxxiii, p. 302 (with review of the subject, histology, with 2 cuts and literature
references).

² Walter Smith, Dublin Jour. Med. Sci., Nov., 1878 (numerous and general, reach­
ing the extreme of three inches in diameter).

³ Laache (Nicolaysen‘s case), Nordiskt Medicinskt Arkiv, 1882, vol. xiv, p. 21—
abs. in Jour. Cutan. Dis., 1885, p. 64 (tumor the size of two fists).

⁴Kaposi, Wien. klin. Wochenschr., 1896, No. 26, and Archiv, 1897, vol. xxxviii,

P. 144.                                                                               

⁵ Duckworth, St. Bartholomew’s Hosp. Reports, vols. iv and vii, reviews literature

to 1872.

⁶ Stelwagon, “The Question of Contagiousness of Molluscum Contagiosum,”
Jour. Cutan. Dis., 1895, p. 50. This paper reviews the literature, with references,
bearing upon this point (numerous examples of contagion in families, schools, asylums,
of accidental inoculation and successful experimental inoculation), citing, among
other English observers, cases observed by Liveing, Morrant Baker, W. Smith, and
Mackenzie; and among other foreign observers, Caillaut, Havenith, Ebert, Tommasoli.

Knowles, “Report of an Institutional Epidemic of Fifty-nine Cases,” Jour. Amer.
Med. Assoc, 1909, vol. liii, p. 671 (with brief review to date, and references); “Mol-
luscum Contagiosum: Report of Ten Family Epidemics and Forty-one Cases in Chil­
dren,” New York Med. Jour., May, 14, 1910 (with reference).

Hartzell, “An Epidemic of Epithelioma (Molluscum) Contagiosum, with some
New Observations Concerning the Molluscum Bodies,” New York Med. Record, June
22, 1912 (with histologic illustrations; epidemic in a large institution for young men,
about 5 per cent, having the disease; the growths were small, but numerous, only on
the trunk and arms).

There is recorded by Paton in the Westminster Hospital Reports, 1908-09, vol. xvi,
p. 11, London, an observation of 7 cases in which operation wounds were infected with
molluscum contagiosum; three small lesions were found on the right hand of the oper­
ating surgeon.

648

NEW GROWTHS

recorded failures at experimental inoculation, including my own, but
these have no weight in the face of successful attempts, even though
scanty in number. The incubation period, as proved in the above
cases, and also by clinical observation, is long—from several weeks to a
few months. Hutchinson, Crocker, and Malcolm Morris¹ have noted
that Turkish baths are a source of contagion—the first stating that most
of his male patients were frequenters of these baths; in such instances,
doubtless, the media of contagion are the towels and gloves.

The disease is seen in both sexes and at all ages, but it is by far most
common in children and among the poor, especially, as in most of my
own cases, in asylums and institutions. Several observers have noted

Fig. 152.—Molluscum contagiosum; section through a small lesion, showing its
epithelial lobular formation, with the connective­ tissue septa separating the lower part
of the lobules; the plug in the central upper part consists of a crowded accumulation of
the so-called “molluscum bodies” (courtesy of Dr. H. G. Piffard).

the occasional coexistence of warts and molluscum contagiosum, but
this does not seem to me unusual, inasmuch as warts are quite common
among the poorer children.

Pathology.—The growth was originally considered, by several
prominent observers, to have its seat in the sebaceous gland (Tilbury
Fox, Kaposi, Leloir, Vidal, and a few others), and the hasty examina­
tion of a tumor is very suggestive of a pathologically changed, lobu-
lated glandular structure; but later and repeated studies, led by
Virchow and confirmed by others (among whom Boeck, Simon, Robin­
son, Crocker, Sangster, Thin, Neisser, Piffard, Fordyce, Gilchrist,

¹ Malcolm Morris, Diseases of the Skin. Graham Little, Brit. Jour. Derm., 1910,
p. 181 (reports 2 cases following Turkish baths; discusses the question of frequency
and infrequency in the cities of Great Britain and Ireland).

MOLLUSCUM CONTAGIOSUM                               649

Kuznitzky), have demonstrated that it takes its origin from the epithe­
lium,—in fact that it is in reality a hyperplasia of the rete or a benign
epithelioma,—and with no connection with the sebaceous gland.
Opinions differ somewhat as to whether it takes its start from the epi­
thelial lining of the hair-follicle or in the rete layer proper.

A vertical section through a molluscum growth shows it to be made
up of several lobules, due to the downgrowth of the rete, which con­
verge toward the apex and broaden toward the base, the fine connective-
tissue septa, formed by the compressed papillæ, which divide them,
appearing continuous, and extending about half-way up, as is clearly
shown in the cut. The upper central part, approaching the outlet,

Fig. 153.—Molluscum contagiosum; transverse section, showing the lobules, the
septa, and the various stages of the cell changes; in the central part the so-called
' molluscum bodies" or “ molluscum corpuscles" (courtesy of Dr. J. A. Fordyce).

where they have fused or converged together, is composed of a mass of
changed epithelial cells, opaque and whitish in color, rounded or ovoid,
somewhat sharply defined, fatty-looking bodies, constituting the so-
called molluscum bodies first described by Patterson. The epithelial
cells in the lower part of the lobules are at first practically unaltered,
but which, as they are crowded up by the underlying proliferation,
undergo degeneration or some peculiar change, become enlarged, and
result in the peculiar formation referred to; others again, instead of the
changes briefly referred to, harden and are more or less cornified. The
whole molluscum lesion is inclosed in a fibrous capsule, the base resting
on the corium. The first change noted in the transformation of the epi­
thelial cell is the appearance within of small, clear, or hyaline bodies,

650

NEW GROWTHS

as a rule close to the nucleus of the cells, usually oval in shape, with
tapering or pointed ends, and containing a nucleus—molluscum bodies;¹
further growth ensues, and finally, in some, a granular-looking mass
results, with a waxy-looking translucent peripheral zone; or, in conse­
quence probably of further growth, degeneration ensues and the cell-
wall and the remaining protoplasm cornify and grow opaque, and the
contents are rendered less recognizable. The term “molluscum body”
or “molluscum corpuscle” has been applied both to the bodies forming
within the cell and to the completely crowded cell, although its proper
or more exact application should be, as Macallum suggests, only to the
former, the cell containing them to be more accurately named the “mol-
luscum cell.”

Although admittedly contagious, what starts the pathologic process
remains yet a mystery. The readiest and most natural explanation,
in the light of other bacteriologic studies, is to be found in the assumption
of a parasitic element, which, I believe, persistent search will yet find.
While it can probably be said that the psorosperm theory, so promis­
ingly lighted by the writings of Darier, Wickham, and others, has been
for some time wholly abandoned, Neisser,² who has contributed much
time to the investigation of this malady, together with a few others
(more especially Bollinger, Mansüroff, Touton, Winogradow, Lindström),
was reluctant to give up the belief in the parasitic character (coccidia)
of the molluscum corpuscles or bodies. In this connection it is inter­
esting to recall that Virchow directed attention to their resemblance to
the gregarinæ of rabbits some years ago. The parasitic character of the
molluscum bodies can scarcely be accepted, however, in view of the
investigations and observations of Boeck, Caspary, Piffard, Crocker,
Török and Tommasoli, Kromayer, Unna, Audry, Macallum, Fordyce,
Lubarsch, and others, which, for the most part, indicate that these in-
tracellular masses are a peculiar form of cell degeneration, of a colloid,
hyaline, or protoplasmic character. C. J. White,³ in a recent valuable
study, concluded that nobody has demonstrated, up to this time, any
parasitic body in the growth, and that the change is not a colloid or
hyaline degeneration, but rather an extraordinary metamorphosis of
rete cells into keratin.

¹ Hartzell, (loc. cit.), in addition to the common findings, found in the area occupied
by the molluscum bodies a few small cells, which he believes has not been described
before; consisting of a perfectly oval body with distinct double wall, entirely filled with
a mass of fine fibrils in which no nucleus could be discovered; the cells of this variety
were so deeply stained that it was extremely difficult to make out details.

² Neisser (Ueber das Epithelioma (sive Molluscum) Contagiosum), Archiv, 1888, p.
553 (with ii cuts); an elaborate and exhaustive paper; the writer deals with the dis­
ease in all its aspects, and gives a complete bibliography; also (Ueber Molluscum Con-
tagiosum), Verhandl. der IV Deutsch. dermatolog. Cong, (with a number of excellent
cuts). These two papers give a review of the contributions and work of others to date.
Other important literature of recent date bearing upon pathology and histology:
Török, Monatshefte, 1892, vol. xv, p. 109 (with references); Lubarsch-Ostertag‘s
Ergebnisse der allgemeinen Pathologie, 1895, abt. ii, p. 398 (with references); Macallum,
Jour. Cutan. Dis., 1892, p. 93 (with good cuts); Beck (Ehrmann‘s laboratory), Archiv,
1896, Bd. xxxvii, p. 167.

³ Chas. J. White and W. H. Robey, Jr., “Molluscum Contagiosum,” Jour. Med.
Research, April, 1902, p. 255 (a personal study, general review, and résumé, with histo-
logic cuts, and full bibliography).

MOLLUSCUM CONTAGIOSUM

651

As bearing upon the pathogenic factor is the observation by Bol-
linger¹ and others, who have remarked upon the resemblance of mollus-
cum tumors to the growths found on the beaks and eyelids of fowls,
especially chickens and pigeons, and with which the observations of
Salzer,² Colcott Fox,³ and Shattock⁴ appear to prove their identity.
Recently Salzer reported a suggestive, but not unquestionable, case
in which the patient had shown the disease about the time some pet
pigeons, which she was in the habit of feeding out of her hand, had
developed growths on the beak. Colcott Fox met with the growths
on the legs, feet, and head of a white Wyandotte chicken, and micro­
scopic examination proved them typical of molluscum contagiosum.
Shattock observed similar growths in two mated sparrows.

Diagnosis.—There should be no difficulty, as a rule, in the
diagnosis, as the size of the lesions, their waxy or glistening appearance,
and the presence of the central depression and orifice are sufficiently
characteristic. The disease is to be differentiated from fibroma, milium,
warts, and acne.

Fibromata are rounded growths of small or large size, always exceed­
ing, when at all developed, that of the tumors of molluscum contagiosum,
and are situated deeply in the skin, or even in the subcutaneous tissue;
the lesions of molluscum contagiosum are superficial, seated in the upper
skin and epidermal tissues, and are, comparatively speaking, small in
size; the tumors of the former have no central orifice, depression, or
opening, while these are usually quite distinct in the latter disease.

Milia resemble the small molluscum growths to some extent, but
are usually whitish, and lack the pearly or waxy appearance and the
central orifice of the latter. These latter characters will also serve to
differentiate it from small warts, to which it bears a rough resemblance;
moreover, warts are harder and more solid. It is scarcely possible to
mistake the disease for acne—small papular acne—as the lesions in this
latter disease are usually seen in all stages of papulation and pustulation.

Prognosis and Treatment.—The prognosis of molluscum
contagiosum is favorable, and it is only exceptionally that any per­
manent trace of the disease is left. In many instances the tumors
will disappear spontaneously in the course of several weeks or a few
months. In others, active measures are necessary to bring about their
removal. All cases should, however, receive prompt treatment, in
order that a possible source of contagion may be removed.

If there are but a few lesions, their contents may be immediately
pressed out, and a deep application, through the central orifice, be
made with a strong solution of silver nitrate or carbolic acid by means
of a sharply pointed stick; or the lesions may first be incised, and then

¹ Bollinger, Virchow‘s Archiv, 1873, vol. lviii, P. 349 (with colored plate).

² Salzer, Münch, med. Wochenschr., 1896, No. 36, p. 841.

³ Colcott Fox, Trans. London Patholog. Soc‘y, 1898, vol. xlix, p. 393 (with illus­
trations).

⁴Shattock, ibid., p. 394 (with illustrations). Recently Lipschütz (Ehrmann's
clinic), Dermatolog. Zeitschr., vol. xiv, H. 8, has repeatedly found in the growths minute
diplococcoid bodies, the two bodies appearing as if close together, but separate, yet
joined by a scarcely recognizable connection.

652

NEW GROWTHS

the cauterization made. If the formations are numerous, and especially
when seated on a limited region, a mild stimulating or parasiticide
ointment should be tried before operating upon individual growths;
for this purpose one containing 20 to 40 grains (1.35-2.65) of white
precipitate or sulphur to the ounce (32.) should be rather vigorously
rubbed into the affected parts once or twice daily; or a drying lotion,
such as the calamin-zinc-oxid lotion, with boric acid solution as the
basis, can be applied freely once or twice daily. A number of my cases
have gone on to recovery under such measures. If this method should,
after trial, prove without effect, the mild operative and cauterizing
applications mentioned are to be resorted to. Lesions which have
become pedunculated may be snipped off with scissors and the base
touched with silver nitrate.

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